OFFICE : SCOPE/PSOC

Application for reimbursement of

Medical Expenses incurred

Name of Employee_________________________________________ Designation__________________________

Pay ________________________

Name of Patient and Relationship Detail Break-up of Amount

Age Expenses

1. Medical Consultation with

Dr.

a) No. (s) of consultation (s) on date

________________@Rs._____per consultation. Rs.____________

b) Administration of Injection/other professional

service___________No. Date________________ Rs.____________

2. Cost of admissible Medicines (precription &

Cash Memo enclosed)

i)________________________ Rs.__________
ii)_______________________ Rs.__________
iii)_______________________ Rs.__________
iv)_______________________ Rs.__________
v)________________________ Rs.__________
vi)_______________________ Rs.__________
vii)______________________ Rs.__________
Cash memo-wise total Rs.____________

3. Investigation for diagnosis/Radiological/ Rs.____________

Pathological and other tests on medical advice.

4. Hospital Expenses :

Rs.____________

Rupees.

The necessary bills/prescriptions in original/duplicate are attached hearwith. I request that the total amount mentioned above
has actually been incurred by me and may please be reimbursed to me.

Also certified that my parents for whom medical expenses have been claimed in this bill is/are wholly dependended
on me and are also residing with me. And that the combined income does not exceed Rs.__________p.m.__________

Date___________ Signature of Claiment_________________________

Passed for Rs.__________________________________________________________________________ Only.

Dated:____________________________________ Signature of the Sanctioning Authority