Professional Documents
Culture Documents
Medical Proforma
Medical Proforma
Rab Nawaz,
Diabetic/Magrine/AVN
5. Vendor No. and PPO No. For retired Government Servant __________________________N.A__________________
6. List of medicines with quantity/hospital bill/laboratory and other diagnostic charges etc. for which reimbursement is
claimed through this bill (format attached).
PART-B
Certificates by Government servant (or member of his family in case of deceased Government servant).
Certified that:i)
The member of my family for whose treatment reimbursement has been claimed is wholly dependent
upon me.
ii)
iii)
I shall have no objection to the recovery of any amount overpaid, if any, from my pay/pension
or otherwise.
Signature ________________________________
FULL NAME OF THE GOVERNMENT SERVANT
or (claimant family member in case of deceased)
RAB NAWAZ
(in block letters)
Dated: ________________
COUNTERSIGNATURES
Departmental Controlling Authority
Hospital Authority
Signature __________________________________
Signature __________________________________
Designation ________________________________
Designation ________________________________
M.Haider Khan/M.Cla.
S.#
1
2
3
4
5
6
7
8
9
10
Amount
Mixtrad Insulin
Tab. Viglip M 50/1000
Cap. Sibelium 5mg
Tab. Hitop 50mg
Cap. Celbex 200 mg
Tab. Neoprox 500mg
Cap. Tramal Plus
Cap. Sante 2mg
Tab. Carsel 50 mg.
BD Syring Insuline 1cc
1992/1440/750/596/960/828/882/356/109/150/-
TOTAL
(Rupees:
(04)
(60)
(60)
(30)
(60)
(90)
(60)
(30)
(30)
(10)
8063/-
M.Haider Khan/M.Cla.
S.#
Name
of
the
Chemist
Shop/Hospital/Clinic/Dispensary
Name
of
Drugs/Medicines with
Quantity/Details
of
Tests etc.
Amount
1
2
3
4
TOTAL
(Rupees
Signature________________________
MUHAMMAD MUZAFFAR KHAN LASHARI
(Full Name of the Government Servant
M.Haider Khan/M.Cla.
S.#
No.3061 dated
23-05-2011
-do-
-do-
-do-
-do-
-do-
-do-
TOTAL
(Rupees Nine Thousand Six Hundred & Thirty only)
M.Haider Khan/M.Cla.
Name of
Drugs/Medicines with
Quantity/Details of
Tests etc.
02 Insulin Humalog
Plain.
01 Insulin Humalog 50
X 50
1 X 100 Dis.Syringes
ICC insolin 100
Teststrip Optium
Glucometer.
Amount
Rs.3,060/Rs.2,700/Rs.1,200/Rs.2,700/Rs.9,630/-
PART-B
Certificates by Government servant (or member of his family in case of deceased Government servant).
Certified that:i)
The member of my family for whose treatment reimbursement has been claimed is wholly dependent
upon me.
ii)
iv)
I shall have no objection to the recovery of any amount overpaid, if any, from my pay/pension
or otherwise.
Signature ________________________________
FULL NAME OF THE GOVERNMENT SERVANT
M.Haider Khan/M.Cla.
COUNTERSIGNATURES
Departmental Controlling Authority
Hospital Authority
Signature __________________________________
Signature __________________________________
Designation ________________________________
Designation ________________________________
M.Haider Khan/M.Cla.