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INDIAN INSTITUTE OF MANAGEMENT KOZHIKODE

FORM FOR MEDICAL REIMBURSEMENT
(FOR OUTPATIENT TREATMENT ONLY)

To

Students Affairs Office

IIM Kozhikode

Sir,
I am submitting herewith medical reimbursement claim of Rs. ______________ on account of medical
expenditure incurred by me for treatment of self at ____________________________________hospital.

Following documents are enclosed herewith duly self attested;

Copy of the prescriptions

Details of Bill Receipts/Cash Memo/Reports as given below;

Sl. No. Details of Bill Receipts/Cash Memo/Reports& Date Amount (in Rs)

Total Amount

I request that the final reimbursed amount may be directly credited to the following bank account;

Name of the bank :

Bank A/c Holder Name :
Account Number :
IFSC Code :
Yours faithfully,

Signature :

Name :

Roll No. :

Date : Mobile No.