Annexure-A, APPLICATION FOR MEDICAL REIMBURSEMENT (OUTDOOR) Employee Type (Regular/Reemployed/Deputation/Contract) 1. Name of Employee, SUNIL MABUT( tr DE Designation AM IS dept Fatting Geu 3. Employee No_ OF 2- ‘4. PaySaleRs__£0,090- Ino 209C61) 5.BasicPay__£¥,00 0 6. Reimbursement claim made for - Outdoor/Dental/Ophthalmic/Injury Duty/Pre-post Hospitalization treatment/Pathological test/Profong treatment etc 7. Contact No.-Mob__ 41034049744 Ph. No. /Extn ‘8, Re-imbursement taken for treatment of ~Self/Spouse/Son* /Daughter*/Widowed mother/ (below 25 ‘years of age of tll he/she gets married or employed, whichever is earlier). Name AMAniSt SUNIL tyes Relation _ SON. age Name Relation ge Name Relation ge Name Relation ee Name. Relation ee Name. Relation Age 9. Whether dependent family member/¥e}/No) 10. Treatment Taken from MOTHERHOCD HesPITaL | SANAIVANVEE bine 11. Whether hospital is nominated/Non-nominated/Out-Station/Govt. Hospital i. If, non-nominated, is the Emergency Certificate enclosed? _— Hf, Outstation, is administrative approval obtained _— ischarge 12 (08/2 > / 16 [05] 22 period of hospitatization__+{ Days 13. Diagnosis/Disease Pucumonire 14, Amount of Claim Rs. 5S, &1/ + 4S20+ 390+ ISso = 65,2H 12, Date of admission/ 15. Reimbursement taken {if any) tll date for dental treatment in financial year. 116. Whether Medical edvance drew {if yes mention the amount) Rs. 117. For all lab tests a self certified copy of investigation reports and prescription is enclosed _\/ 18, Discount offered by hospital/Path lab, if any _— 419, Whether treatment is taken as per entitiement _Ye& i, Ifnot, reason for it_— (Attach all bill in original duly verified, prescription advising medicines/pathologic test and summarized as on the reverse.)Summary of Bills:- Sm] Description of pense/ bit suinesone | APO | pears [ [Outpatior bil Ajangh lOPMetN|z273[ 4104 L520 | pre - het ph pel vrien eee i ee ee Z| Tepe iu ie HEME ten naa bEE SE EI [hogpitetid eta Velof {7% z ee aus h__lOPmeuen xres]agas [240 | post = hedspitergacts, dared 1A] of rore t 7 a Hak IU Auareh NOC] Dinpensny 1 {S50 [nose hespilret pe6, om pushes ts Speciale pox ate 24 4 r H hang tetatwents dared 14/08] word Total 1. hereby certify that allthe above bil/billsis/are true and correct 2. itis also certified that my spouse is a housewife/working in and she/he is Claiming /not claiming medical r-imbursament from her/his employer 3. Claims submitted are not older than sx months. pate_06104| 2022 (sig fe employee) rolling officer ‘[#00/ov.H0D Accounts Branch 1) Amount of claim for re-imbursement Rs. 2) Amount not admissible Rs. 3) Amount to be reimbursement Rs. Manager ‘Account Assistant by/ HOp/HoD