H.P.T.R.

6
MEDICAL CHARGES REIMBURSEMENT FORM
1. Name and Designation BHASKAR MAHAJAN/ HEAD CONSTABLE NO. 95
2. Office in which Employed O/O S.P. Chamba, Po!"# L!$# Chamba
3. asic Pay R%. &'9((/)
!. Name of Patient " #elation with the $laimant S#*.
%. Pe#iod of &llness &+/(9/,(&' -o o$.a/0%
6. P'RT&$()'R* O+ TRE'T,ENT-
I-#m Nam#% Cha/1#% D#-a!% o* Ca%h)M#mo% #-".
.i/ ,edicines .Names/
1. $hlo#o01ine Ta2 36.41 5ide cash memo no. 13637832944 dated
2. :one 1gm &n; 231.4! 14.37.2313 f#om <an '1shadi Rogi =alyan
*amiti6D.R.P.>.,.$. " H. =ang#a at Tanda
TOTAL ,(9.((
.ii/ )a2o#ato#y Tests8'm21lance8$ons1ltancy8&ndoo# Room8 Othe# .*pecify/
1. Diffe#ential )e1cocyte $o1nt 13.33 5ide ill &D627%49% Dated 14.37.13
2. Total )e1?ocyte $o1nt 13.33 6Do6
3. *e#1m >l1cose 33.33 6Do6
!. Renal +1nction Test 63.33 6Do6
%. Haemoglo2in %.33 6Do6
6. *e#1m *odi1m 33.33 6Do6
9. *e#1m Potassi1m 33.33 6Do6
4. Platelets 13.33 6Do6
7. *e#1m P#otein 33.33 5ide ill &D627619! Dated 14.37.13
13. Pe#iphe#al lood *mea# 13.33 6Do6
11. lood (#ea Nit#ogen 33.33 6Do6
12. @eil +eliA 3%.33 6Do6
13. (#ine $1lt1#e %3.33 6Do6
1!. Retic1locyte $o1nt 13.33 6Do6
1%. )iBe# +1nction Tests 123.33 6Do6
16. *e#1m $alci1m 33.33 6Do6
19. (#ine Ro1tine EAamination 33.33 6Do6
14. E#yth#ocyte *edimentation Rate 13.33 6Do6
17. Red lood $ell 13.33 6Do6
23. lood $1lt1#e and *ensitiBity 133.33 6Do6
21. Platelets 13.33 6Do6
22. @idal Test 3%.33 6Do6
TOTAL 295.((
9. Total $laim Rs.,(9329549(5
4. )essC'dBance D#awn Bide T85
NoDDDDDD.DtDDDDDD..RsDDDDDDD..
7. Net 'mo1nt Paya2le R%. 9(5/)
& he#e2y decla#e that the statements in this application a#e t#1e to the 2est of my ?nowledge an
2elief and that the pe#son fo# whom medical eApenses we#e inc1##ed is wholly dependent on me.
DateDDDDDD.. .*ignat1#e of $laimant/
6ERIFICATION CERTIFICATE
&E D#. DDDDDDDDDDDDDDDD.he#e2y ce#tify that Bha%7a/ Maha8a$ s1ffe#ing f#om
DDDDDDDDDDDDDDDand is8was 1nde# my t#eatment f#om &+.(9.&' to o$.a/0% and that the
a2oBe mentioned medicines8tests we#e p#esc#i2ed 2y me in this connection.
The claim is Be#ified fo# Rs. 9(5/)
DateDDDDDD. 9S!1$a-:/# o* M#0!"a O**!"#/;
D#%!1$a-!o$ < S#a
Passed fo# Rs. DDDDDDD..R1peesDDDDDDDDDDDDDDDDDDDDDDDDD/
and incl1ded in ill no. DDDDDDDDDDDDated DDDDDDDDDDDDD
.*ignat1#e of $ont#olling Office#/ .*ignat1#e of DDO/
INSTRUCTIONS
1. )ist all the medicinesE tests etc. indiBid1ally.
2. 'ttach $ash6,emos d1ly Be#ified.
3. ,ention dates of admission to the HospitalE *tay etc.