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1) Sweta Basanta Sethi, a Technical Assistant in the Electronics and Communication Engineering department at the National Institute of Technology, is applying for a refund of 1934 rupees for medical expenses incurred by her mother Laxmi Sethi. 2) Laxmi Sethi suffered from abdomen pain and a urine infection and received consultation, tests, and medicines for treatment. 3) The expenses included a 100 rupee consultation fee, 290 rupees for pathology tests conducted at a local clinic, and 1543.96 rupees for purchased medicines. Bills and documentation are provided as proof of expenses.

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34 views2 pages

Title 2

1) Sweta Basanta Sethi, a Technical Assistant in the Electronics and Communication Engineering department at the National Institute of Technology, is applying for a refund of 1934 rupees for medical expenses incurred by her mother Laxmi Sethi. 2) Laxmi Sethi suffered from abdomen pain and a urine infection and received consultation, tests, and medicines for treatment. 3) The expenses included a 100 rupee consultation fee, 290 rupees for pathology tests conducted at a local clinic, and 1543.96 rupees for purchased medicines. Bills and documentation are provided as proof of expenses.

Uploaded by

Sweta Sethi
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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NATIONAL INSTISTUTE OF TECHNOLOGY

Application for claiming Refund of Medical expenses of Incurred in connection with Medical Treatment
of Institute employees and their Families

1. Name of employee(in block letters): SWETA BASANTA SETHI


Designation: Technical Assistant
2. Department: Electronics and Communication Engg.
3. Residential address: F/62, NIT Campus, Rourkela
4. Name of the patient: smt. Laxmi Sethi
5. Relationship to the employee: Mother
6. Nature of illness: Abdomen Pain(urine infection)

DETAILS OF THE AMOUNT CLAIMED:-

I) Fees for consultation indicating.


a) The name and the designation of the medical officer
Consulted and the hospital or dispensary to which Dr. Manmohan Bisoyi
Attached: M.D.Medicine

b) The number and dates of consultations and the fees paid


For each consultation: 12.10.2016, Rs 100/-

c) Whether consultations were held hospital at the


Consulting Room of the medical officer or at the
Residence of the patient: At the consulting room
Of medical officer.
II) Charges for pathological, bacteriological, radiological or
Other similar tests undertaken during diagnosis indicating:

a) The name of the hospital or Laboratory where the tests


Were undertaken. (MP, urine,TLC,DC) SAI SIDHEE PATHOLOGY
CLINIC(Bhanjanagar)
b) Cost of pathology tests: Rs 290/-

III) Cos of medicines purchased from the market: Rs 1543.96/-


(list of medicines cash memos attached)
7. Total amount claimed : 1933.96/-( rounded to 1934/-)
8. List of enclosures: i) Xerox copy of the prescription, ii) original bills(2nos), iii) Xerox copy of
The medical book.

DECLARATION TO BE SIGNED BY THE EMPLOYEE

I hereby declare that the statements in this application are true to the best of my knowledge
and belief and that the person for whom medical expenses were incurred is wholly dependent
on me.

Date:…………………………….. Signature of Employee:………………………………

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