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Medical ANNEXURE C

This document is a form to be filled out by WAPDA (Water and Power Development Authority) for reimbursing medical claims. It requests information such as the patient and employee's name and relationship, the department where the employee works, hospital and period of admission, and reasons for referring to another hospital. The form is to collect details on the medical case and prescription to process reimbursement claims for employees or their dependents.

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Mirza Sohail Ahmad Soharwardi
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2K views1 page

Medical ANNEXURE C

This document is a form to be filled out by WAPDA (Water and Power Development Authority) for reimbursing medical claims. It requests information such as the patient and employee's name and relationship, the department where the employee works, hospital and period of admission, and reasons for referring to another hospital. The form is to collect details on the medical case and prescription to process reimbursement claims for employees or their dependents.

Uploaded by

Mirza Sohail Ahmad Soharwardi
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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ANNEXURE-C

PERFORMA TO BE FILLED IN BY THE WAPDA


ORGANIZATION/FORMATION FOR THE RE-IMBURSEMENT OF MEDICAL
CLAIM
1. Name of the employee ______________________________
with Designation and BPS ______________________________
2. Name of the Patient and ______________________________
relation with the employee ______________________________
3. Department/Organization where ______________________________
The claimant is presently working ______________________________
4. Whether the claimant is drawing cash medical ______________________________
allowance or opted medical facility ______________________________
______________________________
5. Whether the case was/is i. Govt/Civil ______________________________
referred by the authorized Hospital ______________________________
WAPDA Medical attendant ______________________________
for treatment in any of ii. C.M.H ______________________________
the hospital, indicate name ______________________________
of hospital with its location iii. Private ______________________________
Hospital
6. Period for which the patient remained admitted in ______________________________
hospital ______________________________
7. Name and designation of the authorized WAPDA ______________________________
Medical Attendant who referred the case other ______________________________
than WAPDA Hospital
8. Whether referred chit is attached with medical ______________________________
reimbursement claim ______________________________
9. Reason under which the case of the patient was ______________________________
referred to other than ______________________________
WAPDA Hospital
10. Detail of prescription of medicine ______________________________
Prescribed by the authorized Medical Officer form ______________________________
time to time for purchasing it from the market. ______________________________
Employee Signature

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