Medical Reimbursement Claim Form For Outdoor Treatment

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

Claim Number 00000000000004291915 Personnel Number 00305274

1. Name Of Employee SHIJINESH KUMAR P K

2. Designation DIVISIONAL ENGINEER TELECOM CHALAKUDI

3. Basic Pay + DA (as on 01-04-2022) 123164

4. Place Of Duty Trichur TD

5. Name Of Patient SHIJINESH KUMAR P K

6. Relationship with Employee SELF

7. Age 042

8. Nature Of Illness General

9. Name Of Doctor/Hospital JILSE GEORGE / MEDICAL COLLEGE HOSPITAL

ERNAKULAM
10. Details Of Claim : Date of Claim Submission Aug 9, 2022

(attach prescription, vouchers)

Voucher Date Claim Type Voucher No. Amount

Jul 6, 2022 Consultation 1 300.00

Jun 11, 2022 Consultation 2 300.00

May 2, 2022 Consultation 3 400.00

Jul 6, 2022 Medicines 6056 741.00

Jun 11, 2022 Medicines 4271 754.00

May 2, 2022 Medicines 1617 543.00

TOTAL 3038.00

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)
 Medical Reimbursement Claim Form For Outdoor Treatment
Annexure - C to ( Order Dt. 22 April 2003 )

Claim Number 00000000000004291915 Personnel Number 00305274

Mobile No. 9447055061