6/29/24, 10:27 AM Department of Health and Family Welfare

Department of Medical Health and Family Welfare

Government of Uttar Pradesh

Online Application Form for Registration of Medical Reimbursement

To, Application Number : MER0198798

The Superintendent in Cheif / Chief Medical Superintendent,
Distt : Meerut
Uttar Pradesh
Sir,
Kindly Register my request for issuance of Medical Reimbursement which are given as
below:

1 Treatment Type:

Treatment Category For Both Treatment

2 Employee's Detail:

Full Name HIMANSHU PANWAR Father Name VEERSAIN PANWAR

Designation CONSTABLE Aadhaar No. 942341324404

Date Of Birth 23/01/1997 Gender Male

Mobile No 7217758851

3 PPO detail:

Retired from Employeement No

4 Address of Current Posting :

Office Name COMMANDENT 44 BN PAC Office Incharge Name SHRI SACHINDRA PATEL
MEERUT

Address 44BN PAC HAPUR ROAD State Uttar Pradesh

MEERUT

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6/29/24, 10:27 AM Department of Health and Family Welfare

District Meerut Pincode 250002

5 Permanent Address :

Address vill vpo doghat tehsil baraut State Uttar Pradesh

distt baghpat

District Baghpat Pincode 250622

6 Patient`s Details:

Requesting Medical Dependent Hospital Type Pvt

Reimbursement for

Patient Name RASHMI TOMAR Age 26

Gender Female Disease Name PREGNENCY AND

DELEVERY TREATMENT

Place where Disease baghpat Hospital Name JIWANI HOSPITAL

Identified

Doctor Name Dr FIRDOSH Treatment Period From 04/08/2023

Treatment Period To 02/03/2024 Patient Aadhaar no

Relations with Employee wife

7 Details of expenditure:

S.No. Bill Type Bill No. Date Amount Download

1 Medicine A001741 04/08/2023 359.00


2 Medicine A002210 04/09/2023 380.00

3 Medicine A002407 18/09/2023 641.00

4 Medicine A002721 13/10/2023 750.00


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6/29/24, 10:27 AM Department of Health and Family Welfare

S.No. Bill Type Bill No. Date Amount Download

5 Medicine A002889 28/10/2023 1488.00


6 Medicine A003447 27/01/2024 784.00

7 Medicine A003584 07/02/2024 1426.00

8 Medicine A018842 02/03/2024 927.00

9 Hospital Bill 810 02/03/2024 37500.00

Total 44255.00

8 Advance Detail:

Have you already taken No

Advance

9 Bank Details of Employee:

Bank Name BANK OF BARODA Branch Name SHAMLI

Account Number 35810100013317 IFSC Code BARB0SHAMLI

Date Place Signature of Person Incharge

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