MEDICAL REIMBURSEMENT (Supported by BILLS)
HRMS
APPLICATION PARTICULARS
EMPLOYEE DETAILS For SELF
PF Index No 8091439 Emp No./PERNR 00809143
Name Nijila Felcin T C Branch / Office Ambathurai
Request No MDO0011115950 Request Date 27.05.2024
Bank Account No. 20376483343 Designation Associate (CSS)
Cadre Clerical Mobile No 9489483009
Date of Joining 02.01.2017 Intercom No.
Cost Center AMBATHURAI Department (fill manually, if required):
APPROVER DETAILS
1. Ranjith Arun 2. 3.
CLAIM DETAILS
Type of Reimbursement: HOSPITALISATION EXP.
Nature of illness: Maternity
Treatment Taken By: Nijila Felcin T C Age: 030 Relationship: SELF
Period of Treatment From : 14.01.2024 To: 15.01.2024
Name of Doctor: Dr M Santhi Qualification of Doctor: MD DGO ART MRM
Name of Hospital: Whether Hospital Empanelled ?:
Address of Hospital:
Hospitalisation From: 00.00.0000 To: 00.00.0000 Days: 0000
Major Head-Wise Summary of Expenditure incurred
Classification of Expenses Amount (Rs.)
CONSULTATION FEES 850.00
REGISTRATION CHARGES 200.00
BED CHARGES-EXCL. DIET CHARGES 750.00
NURSING CHARGES 100.00
OTHER EXPENSES 900.00
TOTAL EXPENSES
Total Bill Amount: Rs. 2800.00 Amount of Advance Taken if any: Rs. 0.00
Total Amount Claimed: Rs. 2800.00
Certificate:
* I certify that the expenses as detailed above were actually incurred by me.
* It is further certified that I have not received nor am entitled to any reimbursement on contribution towards such expenses under
a personal accident policy or under my claim in respect of an accident or from any other source.
I Further certify that:
* The expenses as detailed above were actually incurred by me for family members wholly dependent on me.(This undertaking will be taken
cognizance of only in case of claim for treatment taken by family members.)
* I further certify that my parent/s is/are wholly dependent on me and ordinarily residing with me. Further my other brothers/sisters
if working in the Bank/any other organization, they have not claimed/are not claiming reimbursement of such expenses.(This undertaking will be
taken cognizance of only in case of claim for treatment taken by parent/s.)
* My parents are not having the monthly income exceeding the limits prescribed by the Bank.(This undertaking will be taken cognizance of only in
case of claim for treatment taken by parent/s only.)
* The family member for which the reimbursement has been claimed does not have a monthly income exceeding the limit prescribed for the
purpose in terms of the extant instructions in this regard.(This undertaking will be taken cognizance of only in case of claim for treatment taken
by family members.)
* My spouse is not employed elsewhere or if employed, he/she is not entitled for reimbursement of the Medical expenses incurred.
/My employed spouse is eligible for the medical facility to the extent of Rs.0 during the calendar/financial year from his/her employer.(This
undertaking will be taken cognizance of only in case of claim for treatment taken by spouse.)
* In case of treatment taken at other than the centre of posting/approved leased accommodation, necessary approval has been obtained and
copy of approval has been attached with the claim.
* In case of claim for Implant/Other transplant, necessary administrative approval has been obtained.
* This excludes children having a monthly income exceeding the limit prescribed for the purpose and also married children irrespective of
income.(This undertaking will be taken cognizance of only in case of claim for treatment taken by child/ren.)
Emp No./PERNR : 00809143 Request No : MDO0011115950 Name: Nijila Felcin T C
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* In case of Dental Treatment (applicable in case of officers only) necessary prior approval from the competent authority has been obtained.
The Bills, receipts, supporting vouchers, prescription etc, and copy of the approval/s, where required, are enclosed with printed copy
of this claim.
Date:27.05.2024 Signature of Employee
( Authorised doctor's certificate to be obtained where the treatment is taken from a physician other than the Bank's Authorised Doctor in addition to his counter signature
on the respective cash memos and receipts.)
I have scrutinized the bills and have found the claims made herein by the employee to be reasonable.
Place: Date: Signature of the Bank's Authorized Doctor
Certificate from the Forwarding Authority
The bill(s) has/have been scrutinized by me in terms of the instructions laid down in this regard from time to time. The claim
may be passed for payment for Rs. 2800.00 ( two thousand eight hundred rupees only).
Date: Head of the Dept./Branch Manager
For Office Use
Sanctioned for payment Rs.__________________(Rupees_________________________________________________
______________________________________________________only) by debit to appropriate Charges BGL account.
Of the total Sanctioned amount Rs.
Amount Taxable
Amount Non-Taxable@@@
Remarks:
Date Sanctioning Authority
@@@ Amount Exempted from income Tax for Treatment of / at Specified Diseases / Hospitals u/s 17 of IT Act is ONLY required to be
mentioned here.
MAJOR HEAD WISE DETAILS OF EXPENSES INCURRED ANNEXURE
classification of expenses Name of the Doctor/Chemist/Lab/Hospital Bill/Cash Memo No. Dated Amount (Rs.)
CONSULTATION FEES Dr M Santhi 038012024 15.01.2024 850.00
REGISTRATION CHARGES Dr M Santhi 038012024 15.01.2024 200.00
BED CHARGES-EXCL. DIET Dr M Santhi 038012024 15.01.2024 750.00
CHARGES
NURSING CHARGES Dr M Santhi 038012024 15.01.2024 100.00
OTHER EXPENSES Dr M Santhi 038012024 15.01.2024 900.00
Total 2800.00
Emp No./PERNR : 00809143 Request No : MDO0011115950 Name: Nijila Felcin T C
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