Medical Reimbursement Claim Form For Outdoor Treatment

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

Claim Number 00000000000003535611 Personnel Number 98102723

1. Name Of Employee MAHESH RANI

2. Designation SUB DIVISIONAL ENGINEER L/C BT

3. Basic Pay + DA (as on 01-04-2019) 92577

4. Place Of Duty Bhatinda TD

5. Name Of Patient MAHESH RANI

6. Relationship with Employee SELF

7. Age 057

8. Nature Of Illness General

9. Name Of Doctor/Hospital Rupinder Singh Sidhu / MALWA HOSPITAL POWER

HOUSE ROAD BATHINDA
10. Details Of Claim : Date of Claim Submission Jul 25, 2019

(attach prescription, vouchers)

Voucher Date Claim Type Voucher No. Amount

Jul 24, 2019 Consultation 52753 200.00

Jul 24, 2019 Medicines 0005955 430.00

TOTAL 630.00

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. 9417800899