Medical Outdoor Opth/Path

Employee Number: 00012554 Name: BAROKA MANOJ

Designation: SR.CUSTOMER RELATIONS ASSISTANT Department : OPERATIONS M

Basic Pay: 41390.00 Pay Scale: 37000-115000 - Sup 1

Mobile No.: Claim Status: Partially Approved

Reference Number: 0001255400039 Request Type: Claim

Requested
13557.00 Approved Amount: 13557.00
Amount:

If Cashless Facility Availed : Investigation Reports : YES

Administartive Approval : NO Discount offered by Hospital : YES

Claim for the Year of : NO Emergency Certificate Encl.

Whether Treatment is Taken : YES HR Bundle Number :

Whether hospital is : NOMINATED Discharge Bill Break up Attached :

Hospital : MAX HOSPITAL G Other Hospital :

Diagnosis/Disease : PREGNANCY If not,Reason for it :

Date of Discharge : Date of Admission :

Period of Hospitalization : 00000 Reimbursement Claim made for : OTHERS

Dependents :
Name Full Name Birth date Age Years
Spouse MANISHA . 06.07.1992 026

Line Number Expense Type Description of Expense Bill No Date Requested Amount
0001 OTHERS/PROCEDURE ULTRASOUND 1764885 Sep 20, 2018 2,660
0002 OTHERS/PROCEDURE ULTRASOUND 1804091 Nov 30, 2018 3,281
0003 OTHERS/PROCEDURE ULTRASOUND 1812025 Dec 16, 2018 1,734
0004 OTHERS/PROCEDURE ULTRASOUND 1833150 Jan 28, 2019 2,941
0005 OTHERS/PROCEDURE ULTRASOUND 1848476 Feb 25, 2019 2,941