Medical Reimbursement Claim Form For Outdoor Treatment

Annexure - C to ( Order Dt. 22 April 2003 )

Claim Number 00000000000004671071 Personnel Number 00401842

1. Name Of Employee RAM KUMAR

2. Designation TT TRANS I S 17 CHANDiGARH

3. Basic Pay + DA (as on 01-04-2023) 52479

4. Place Of Duty Chandigarh TD

5. Name Of Patient LATA DEVI

6. Relationship with Employee Spouse

7. Age 037

8. Nature Of Illness General

9. Name Of Doctor/Hospital Vaidya Karanvir Singh / CHANDIGARH AYURVED

&PANCHKARMA CENTRE
10. Details Of Claim : Date of Claim Submission Dec 14, 2023

(attach prescription, vouchers)

Voucher Date Claim Type Voucher No. Amount

Dec 6, 2023 Consultation 23-24/NO-3088 500.00

Dec 6, 2023 Medicines 23-24/NO-3088 3225.00

TOTAL 3725.00

Declaration : I hereby declare that the statements given in application are true to the best of my knowledge
and belief and that the person for which medical expenses are incurred is wholly dependent on me.

(Signature of Employee)

Mobile No. 9464544447