MEDICAL REIMBURSEMENT FORM IN ELECTRONIC FORM.

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January 17, 2012 | FORMS, MEDICAL REIMBURSEMENT FORMS | Post by: admin

HERE ARE THE MEDICAL REIMBURSEMENT FORMS NEED TO CLAIM A MEDICAL BILL……..

MEDICAL REIMBURSEMENT FORM

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2 comments on “MEDICAL REIMBURSEMENT FORM IN ELECTRONIC FORM.

  1. MEHRA TARAN on said:

    ANYONE PLEASE TEL ME HOW TO UPLOAD DATA ON THIS SITE IN A PROPER MANNER.

  2. MEHRA TARAN on said:

    mYfIkl ibl sbMDI cYk ilst
    1. hwN ieh ib`l srkwr v`loN qih kIqI rwSI________/-ru: q`k hY, ies qoN v`D hox qy ijs dI mnjUrI srkwr v`loN jwrI kIqI jwxI hY[
    2. hwN ieh ib`l ielwj qoN Cy mhIny AMdr hI ivBwg nMU pys kIqw igAw hY[ iesdw fwierI nM______imqI________hY[
    3. pRqI purqI leI dvwieAwN dI pustI sihq ivBwg v`loN kIqI jw skdI hY[
    4. pRqI pUrqI Aqy nw pRqI pUrqI leI Xog srkwrI drwN Anuswr ktoqI auprMq drj kIqIAwN geIAwN hn, ijs sbMDI kwrvweI fI.AYc.Ays pMjwb dy d&qr v`lO kIqI geI hY[
    5. hwN klym ieMfor ielwj nwl sbMDq hY[
    6. hwN ibl dw joV shI hY[
    7. hwN ibl srkwr v`loN smyN smyN isr imilAwN hdwieqwN Anuswr hI iqAwr kIqw igAw hY[
    8. hwN klyNmYNt ie`k_____________Aqy ^jwnw A&sr___________rwhNI pYnsn frwA kr irhw hY[ ieh mYfIkl B`qw nhIN/ hwN lY irhw hY[
    9. klymYNt ny cwlU iv`qI swl dorwn koeI Awaut for ^rc klym nhIN kIqw[
    10. hwN, ib`l sbMDI mYfIkl A&sr pwsoN qsdIk hY[
    11. hwN ib`l hYf Awi&s rwhIN ByijAw igAw hY[
    12. ies ibl dI adwiegI ly^w m`d_________________iv`coN kIqI jwxI hY[
    13. hwN dvweIAwN dw nwm mYfIkl rI-ieMbrsmYNt srtIi&kyt Aqy ilst iv`c drj kr ilAw igAw hY[
    14. hwN mYfIkl ib`l sbMDI ishq ivBwg v`loNjwrI hdwieqwN Answr kwrvweI kIqI jwNdI hY[
    15. nw-pRqI pUrqI Xog dvweIAwN srkwrI drwN Anuswr qsdIk auprMq k`itAwN geIAwN hn, ijhnwN dI ktoqI fI.AYc.AYs pMjwb dy d&qr v`loN kIqI jwxI hY[
    16. fweIt cwrt klym iv`c Swiml nhIN hn[
    17. pI.jI.AweI cMfIgV qoN ielwvw iksy Aspqwl dy rUm ryt cwrj Swiml kIqy nhIN jwNdy[
    18. klyNmYNt ny Awpxy____________________________ dw ielwj hY[
    19. lwgU nhIN ikauN jo ies sbMDI srkwr dIAwN hdwieqwN imqI________Anuswr soD ho cu`kI hY[
    20. hwN, AMfrtyikMg klym nwl n`QI hY[
    21-22-23 – pMjwb srkwr isi^Aw ivBwg p`qr nM:___SRI_________imqI:________Anuswr pRvwngI iml c`ukI hY jo Asl hI klym nwl n`QI hY[24._________________________________________________

    krmcwrI dy dsq^q skUl mu^I

    UNDERTAKING CERTIFICATE

    See proviso of Para (ii) of letter No.12/69/98-5HBV/21329 DATED:1/9/2K

    I Jasvir Kaur d/o Sh.Rajinder Singh a resident #392/1A, Sector-44A, Chandigarh do hereby solemnly affirm & declare that :

    1. I Jasvir Kaur certify that Mr.Rajinder Singh (father) is a patient of Gangenous Umbilical Omentocoele and undertaking the treatment from Dr. Sethi’s: The Surgical Hospital & Laproscopy Centre, Tagore Nagar, Ludhiana.

    2. I am submitting a Medical Reimbursement bill of amounting Rs. 23,021/- (Twenty Three Thousand & Twenty One Only) Period of treatment is from 18/04/2012 to 20/04/2012= 3days.

    3. I have not received any aid or received from any other source including medical insurance / Accidental insurance.

    Seal of School Signature of the applicant

    d&qr:mu^ AiDAwpk, srkwrI hweI skUl,^yVw &iqhgV swihb[

    hukm nM:___/12 imqI:16/07/2012

    syvw iv^y

    ijlw isi^Aw A&sr,(sY:is)
    &iqhgV swihb[

    ivSw: SRImqI jsvIr kOr ihMdI imstRYs s.hw.s,^yVw (&.g.s) mYfIkl irMbrsmYNt klym krn dw kys Byjx sbMDI[

    bynqI hY ik Awp jI nUM srkwrI hweI skUl,^yVw dy SRImqI jsvIr kOr ihMdI imstRYs s.hw.s,^yVw (&.g.s) dw mYfIkl irMbrsmYNt klym krn dw kys do prqwN iv`c iqAwr krky AglyrI Aqy Xog kwrvweI leI ByijAw jwNdw hY[ ibl iv`c Asl hspqwl dI pricAwN n`QI kIqIAwN geIAwN hn[

    DMnvwd sihq[

    Awp jI dw ivSvwspwqr,

    d&qr : mu`^ AiDAwpk, srkwrI hweI skUl,^yVw &iqhgV swihb[
    hukm nM:___/12 imqI : 16/07/2012

    cYk ilst

     ibl pR&ormw[

     mYfIkl irMbrsmYNt klym pR&ormw[

     &weInl ibl[

     hspqwl dIAwN rsIdwN[

     dvweIAwN dI iftyl[

     AweI.pI.fI. rsIt[

     AMfrtyikMg srtIi&kyt[

     AY&IfYivt[

     mYfIkl ibl sMbMDI cYk ilst[

    skUl mu^I

    d&qr: m`u^ AiDAwpk, srkwrI hweI skUl ,^yVw &iqhgV swihb[

    AMfrtyikMg srtIi&kyt

    qsdIk kIqw jwNdw hY ik SRImqI jsvIr kOr (ihMdI imstRYs) s.hw.s,^yVw &iqhgV swihb, ijnwN ny Awpxy ipqw jI SRI rijMdr isMG dw mYfIkl irMbrsmYNt dw ibl pyS kIqw hY, dy ipqw jI dI mwisk Awmdn ie`k hjwr rupey qoN bhuq G`t hY Aqy auh pYnSn vI klym nhIN krdy[

    skUl mu^I

    PERFORMA FOR MEDICAL REIMBURSEMENT BILL
    1. NAME OF THE CLAIMANT :
    1. DESIGNATION :
    1. BASIC PAY :
    2. BRANCH IN WHICH WORKING : GOVT.HIGH SCHOOL, KHERA(FGS)
    3. RELATION WITH THE CLAIMANT :
    4. NAME OF THE PATIENT :
    5. DURATION OF TREATMENT :
    6. NAME OF HOSPITAL :
    7. NO. & DATE OF PRESCRIPTION :
    8. AMOUNT CLAIMED FOR RE-IMBURSEM. : RS. __________/-
    9. Name of dealer from whom medicines
    Purchased and no. and date along with
    The total amount of the cash memo
    issued by him. :
    NAME & DESIGNATION OF THE COUNTER-
    SIGNING AMOUNT OF AUTHORITY. : HEADMASTER, GHS, KHERA FGS
    DECLARATION:
    6. I hereby declare that the medicines purchased for the treatment of the patient have already been entirely consumed.
    7. I hereby declare that the treatment for which the charge is being claimed is not preferred during the currency of the treatment.
    8. I hereby declare that the treatment for______________________________________ for the above mentioned period has got from________________________________ and further certify that the claim for the above mentioned period from any other dispensary (Except the one stated above) has not been prefferd previously nor will be preferred in future.
    9. It has further that the dependent/ family member viz_______________________in respect of whom treatment medical reimbursement of Rs._____________/- is being claimed is employed in the office of GOVT. HIGH SCHOOL, KHERA FGS which is in PUNJAB STATE, is situated at a distance of 44kms from Chandigarh.
    10. It is certified that He/ she has not claimed the above amount from his/ Her office nor he will claim the amount after bill in future
    In case the claim of expenditure involves more than six months from the date of expiry of implement, the movement Performa in duplicate is attatched.

    Signature of the Claimant
    Certified that the claims has been checked and round correct in all respects.

    Signature of Head office

    MEDICAL REIMBURSEMENT CLAIM PERFORMA

    I certify that _______________________________________ employed in GOVT. HIGH SCHOOL, KHERA (FATEHGARH SAHIB). The under mentioned medicines prescribed by me in this connection were absolutely essential for the treatment and recovery prevention of serious deterioration in the condition of the patient. The medicines were not stocked in the _________________________________________________________________________________________________________________________ for supply to entitled patients and don’t include proprietary preparations for which cheaper substitute of equal therapeutics value are available nor preparation which are primarily food, toilets or disinfections.
    1. Certified that the facilities for the treatment for which the patient was referred to were not available in the Hospital/ Dispensary.
    2. Certified that the I.P was entitled to medical benefit during the period of treatment.
    3. Certified that the medicines were not available in the stock of Hospital/ Dispensary.
    4. Certified that the medicines prescribed are borne of Pharmocopia.
    5. Period of treatment from:
    6. Certified that the treatment as per prescription was necessary.
    7. Certified that price claimed is reasonable.
    8. She was suffering from:_____________________________________________
    SR.
    NO. Name of Medicines Outdoor ticket no./ date on which Prescribed Date on which actually purchased Price Remarks
    1
    2
    3
    4
    5
    6
    7
    8
    9
    10
    11
    12
    13
    14
    15
    16
    17
    GRAND TOTAL

    Signature of Medical Officer/ Superintendent

    4. Certified that ________________________ is my mother and she is dependent upon me and residing with me.
    5. Certified that the medicines have been purchased by me and consumed by me.
    6. Certified that the basic pay is Rs.18180+5000=23180.
    Signature of Applicant
    MEDICAL RE-IMBURSEMENT BILL FORM
    For treasury office use only TOKEN NO. FOR THE MONTH OF : JAN’ 2013
    Treasury/Sub
    Treasury Code
    F
    G
    S
    0
    0
    FATEHGARH SAHIB
    DDO CODE 0 0 4 HEADMASTER
    BILL NO. /MED. REIMB. DATED: __/01/2013
    DEMAND NO. 0 5 EDUCATION DEPTT.
    MAJOR HEAD 2 2 0 2 GENERAL EDUCATION
    SUB HEAD 0 2 SECONDARY EDUCATION
    MINOR HEAD 1 0 9 GOVT. SECONDARY SCHOOL
    SUB HEAD 0 1 NON-PLAN
    DETAILED HEAD 0 0 —————————————–
    SOE 9 1 MEDICAL CLAIM
    SUB SOE 0 0 ————————
    PLAN/NON-PLAN/CSS PROVISINAL P1, CENTRAL C1 NON- PLAN ”P for Plan ”S” for CSS (N” for Non-plan) Voted Charged V (“V for Voted) (“C for Charge
    Sr.No. VOUCHER NO. DESCRIPTION OF CHARGES AMOUNT Remarks
    1 2 3 4 5
    1 SRImqI mnjIq kOr (A/k tIcr), shws, ^yVw
    (&-g-s) iftyl Asl vocr n`QI hn[ 1,26,053 ieh mMnjUrI p`qr nM: Anuswr klym kIqI jwNdI hY[
    k`ul joV = 1,26,053/-
    ( kyvl ie`k l`^ C`bI hjwr qrvMjw rupey )

    CERTIFICATE
    1.Certified that necessaries entries have been made in the Medical Re-Imbursement Check Register.
    2.Certified that the expenditure included in this bill is within the Budget allotment as per detailed given below:
    3.Certifed that the Medical bill has been submitted in this office in time.
    Allotment for the Current year: Rs.126053
    Amount of Present Bill: Rs.126053
    Amount of Previous Bill: . Rs. NIL
    Total: Rs.126053
    Balance Advance: Rs. NIL
    Head of Officer & Designation
    FOR USE IN TREASURY/ PAY & ACCOUNTS OFFICE ONLY
    Pay Rs. (Rs.___________________ only be cash/ cheque/draft account credit as under Rs.___________(Rs._____________only) by adjustment as under.
    District Treasury Officer/ treasury officer/Pay & accounts Officer
    (Audit register page For Use in Accountant General Office Admitted Rs. Objected to Rs.
    vrqoN srtIi&kt
    • skUl dw nwN:
    • kl`str dw nwN:
    • sI.dI blwk dw nwN:
    • Awr.AYm.AYs.ey ADIn pRwpq gwRNt dw nwN:
    • pRwpq hox dI imqI:
    • pwRpq gwRNt dI rkm:
    • ^rcI gwRNt dI rkm:
    • bkwieAw rkm:

    qsdIk kIqw jwNdw hY ik auprokq gWRt ik mMqv leI imlI sI, ausy vwsqy inXmwN Anuswr ^rcI geI hY Aqy ^rc kIqI rkm mqw bu`ks, kYS bu`k, stwk rijstr nwl myl ^wNdI hY[ kIqy gey kMm dIAwN igxqIAwN dw pUrw irkwrf r`i^Aw igAw hY Aqy AMiqm iblwN au`qy tUr mYnyjmyNt kmytI v`loN qsdIk kIqw igAw hY[




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