Department of Medical Health and Family Welfare

Government of Uttar Pradesh

Online Application Form for Registration of Medical Reimbursement

To, Application Number : MER0190486

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 ANKUSH TOMAR Father Name SAHENDRA SINGH

Designation CONSTABLE Aadhaar No. 706327588235

Date Of Birth 15/03/1997 Gender Male

Mobile No 7678379165

3 PPO detail:

Retired from Employeement No

4 Address of Current Posting :

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

Address 44 BN PAC HAPUR ROAD State Uttar Pradesh

MEERUT

District Meerut Pincode 250002

5 Permanent Address :

Address VILL POST GONGAKHERI State Uttar Pradesh

TEHSIL BARAUT DISTT
BAGHPAT
 District Baghpat Pincode 250621

6 Patient`s Details:

Requesting Medical Dependent Hospital Type Pvt

Reimbursement for

Patient Name NIKKI Age 25

Gender Female Disease Name PREGNENCY AND

DELIVERY TREATMENT

Place where Disease LONI GHAZIABAD Hospital Name MAVI NURSING HOME
Identified

Doctor Name DR KAMINI PANWAR Treatment Period From 08/06/2023

Treatment Period To 07/03/2024 Patient Aadhaar no

Relations with Employee WIFE

7 Details of expenditure:

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

1 Pathology 20234347748 08/06/2023 1079.00


2 Pathology 20236150959 09/11/2023 399.00

3 Pathology 20236150740 09/11/2023 1299.00

4 Medicine 29982 09/10/2023 531.00

5 Medicine 31101 10/11/2023 1535.00

6 Medicine 29214 18/09/2023 1468.00

7 Medicine 32388 08/12/2023 2529.00

8 Medicine 26277 10/06/2023 1254.00

9 Medicine 49466 07/03/2024 2124.00

10 Medicine 34285 28/12/2023 3373.00

 S.No. Bill Type Bill No. Date Amount Download

11 Hospital Bill 6175 07/03/2024 24000.00


Total 39591.00

8 Advance Detail:

Have you already taken No

Advance

9 Bank Details of Employee:

Bank Name BANK OF BARODA Branch Name SHAMLI

Account Number 35810100013335 IFSC Code BARB0SHAMLI

Date Place Signature of Person Incharge