To, Date:

The Principal,
Engineering Institute for Junior Executives,
Howrah- 711104

Sub: Submission of claim forms for reimbursement of medical treatment expense.

Sir,
This is to draw your kind attention that my son SWAPNIL DAS has received an OPD consultation on
at Nightingale Hospital, Kolkata as a routine treatment for the disease THALLASAEMIA.
The total medical cost incurred for the same consists of the following:

1.
2.
3.

Documents supporting my statement in line with the respective claim forms are attached herewith
for your kind perusal.
This is my earnest request to you to take necessary action for reimbursement of the same.

With regards,

Lecturer in Metallurgical Engineering

To, Date:
The Principal,
Engineering Institute for Junior Executives,
Howrah- 711104

Sub: Submission of claim forms for reimbursement of medical treatment expense.

Sir,
This is to draw your kind attention that my son SWAPNIL DAS has received a Day Care Treatment for
blood transfusion on 04.10.2018 at Narayana Superspeciality Hospital, Kolkata as a routine
treatment for the disease THALLASAEMIA.
The total medical cost incurred for the same consists of the following:

1. OPD consultation: Rs. 250/-

2. Room Rent / Ward for day care Rs. 500/-
3. Investigations: Rs. 680/-
4. Blood & Medicine: Rs. 400/-
5. Pharmacy and Blood filter: Rs. 938/-
Total: Rs. 2768/-
Documents supporting my statement in line with the respective claim forms are attached herewith
for your kind perusal.
This is my earnest request to you to take necessary action for reimbursement of the same.

With regards,

Lecturer in Metallurgical Engineering

To, Date: 25/09/2018
The Principal,
Engineering Institute for Junior Executives,
Howrah- 711104

Sub: Submission of claim forms for reimbursement of medical treatment expense.

Sir,
This is to draw your kind attention that my son SWATTIK DAS has received an OPD consultation of
specialist cardiologist on 14/08/2018 at Narayana Superspeciality Hospital, Howrah for cardiac pain.
The total medical cost incurred for the same consists of the following:

1. OPD consultation Rs. 250/-

2. Echo screening test (code 02020003) Rs. 720/-
Total Rs. 970/-

Documents supporting my statement in line with the respective claim forms are attached herewith
for your kind perusal.
This is my earnest request to you to take necessary action for reimbursement of the same.

With regards,

Lecturer in Metallurgical Engineering

To, Date:
The Principal,
Engineering Institute for Junior Executives,
Howrah- 711104

Sub: Submission of claim forms for reimbursement of medical treatment expense.

Sir,
This is to draw your kind attention that my son SWAPNIL DAS has received a Day Care Treatment for
blood transfusion on 24.10.2018 at Narayana Superspeciality Hospital, Kolkata as a routine
treatment for the disease THALLASAEMIA.
The total medical cost incurred for the same consists of the following:

1. Room Rent / Ward for day care Rs. 500/-

2. Investigations: Rs. 600/-
3. Blood & Medicine : Rs. 3964/-
4. Pharmacy: Rs. 348/-
Total: Rs. 5412/-
Documents supporting my statement in line with the respective claim forms are attached herewith
for your kind perusal.
This is my earnest request to you to take necessary action for reimbursement of the same.

With regards,

Lecturer in Metallurgical Engineering

To, Date:
The Principal,
Engineering Institute for Junior Executives,
Howrah- 711104

Sub: Submission of claim forms for reimbursement of medical treatment expense.

Sir,
This is to draw your kind attention that my son SWAPNIL DAS has received a Day Care Treatment for
blood transfusion on 04.10.2018 at Narayana Superspeciality Hospital, Kolkata as a routine
treatment for the disease THALLASAEMIA.
The total medical cost incurred for the same consists of the following:

1. OPD consultation: Rs. 250/-

2. Room Rent / Ward for day care Rs. 500/-
3. Investigations: Rs. 680/-
4. Blood & Medicine: Rs. 400/-
5. Pharmacy and Blood filter: Rs. 938/-
Total: Rs. 2768/-
Documents supporting my statement in line with the respective claim forms are attached herewith
for your kind perusal.
This is my earnest request to you to take necessary action for reimbursement of the same.

With regards,

Lecturer in Metallurgical Engineering

To, Date:
The Principal,
Engineering Institute for Junior Executives,
Howrah- 711104

Sub: Submission of claim forms for reimbursement of medical treatment expense.

Sir,
This is to draw your kind attention that my son SWAPNIL DAS has received a Day Care Treatment for
blood transfusion on 01.12.2018 at Narayana Superspeciality Hospital, Kolkata as a routine
treatment for the disease THALLASAEMIA.
The total medical cost incurred for the same consists of the following:

1. Room Rent / Ward for day care Rs. 500/-

2. Investigations: Rs. 730/-
3. Blood & Medicine: Rs. 3964/-
4. Pharmacy and Blood filter: Rs. 873/-
Total: Rs. 6067/-
Documents supporting my statement in line with the respective claim forms are attached herewith
for your kind perusal.
This is my earnest request to you to take necessary action for reimbursement of the same.

With regards,

Lecturer in Metallurgical Engineering