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Form 2

This document is a medical expenses claim voucher for employee V. Phani Raj, detailing a total claim amount of Rs. 4,920.50 for outpatient treatment and medicines received at Seven Hills Hospital, Visakhapatnam. The claim includes three bills dated June 10, 2025, and is currently pending approval. The employee has declared the accuracy of the information and the dependency of the patient on them.

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phani
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44 views1 page

Form 2

This document is a medical expenses claim voucher for employee V. Phani Raj, detailing a total claim amount of Rs. 4,920.50 for outpatient treatment and medicines received at Seven Hills Hospital, Visakhapatnam. The claim includes three bills dated June 10, 2025, and is currently pending approval. The employee has declared the accuracy of the information and the dependency of the patient on them.

Uploaded by

phani
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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MEDICAL EXPENSES CLAIM-CUM-VOUCHER-00000000000013837067/16.06.

2025

Employee No 00512672 Grade B


Employee Name V. Phani Raj
Designation Asst. Manager (Engg.)
Department Engineering Location Bhubaneswar DO
Contact No./Address Present Address Details: Tel No. : - ; Mobile No. : 919700351546
PLOT NO.211/5796, PRAGATI VIHAR NEAR ROYAL ENCLAVE, CHANDRASEKHARPUR
OR, Bhubane
Document Type Prescription
MedOutstn. Decl. No.
Treatment Category Nominated
Treatment Availed As Out Patient Treatment Type - Non-Ayurveda
Advance No. (if taken) Claim Ref. No. 13837067/16.06.2025

Claim Details

Patient Name Doctor/Hospital Name Bill Date Bill No Covid Type Bill Amount
Vadthya Neela SEVEN HILLS No Consultancy 700.00
HOSPITAL,Visakhapatnam 10.06.2025 9426010035
878
Vadthya Neela SEVEN HILLS No MEDICINES 2950.00
HOSPITAL,Visakhapatnam 10.06.2025 9426101780
6
Vadthya Neela SEVEN HILLS CA38121 No MEDICINES 1270.50
HOSPITAL,Visakhapatnam 10.06.2025
Bill Amount (Rs) 4,920.50 (FOUR THOUSAND NINE HUNDRED TWENTY & PAISE FIFTY ONLY)

Claim Amount (Rs) 4,920.50 (FOUR THOUSAND NINE HUNDRED TWENTY & PAISE FIFTY ONLY)

Number of Enclosure : 03

DECLARATION : I hereby declare that the above statements are true and the person for whom medical expenses have
been claimed are wholly dependent upon me and are residing with me under the same roof. I certify that the medicines
shown against the bill(s) above are not for a period of more than one month.

Signature of the Employee

Date Approved By Designation : Status


Pending for Approval
FOR OFFICE USE
Passed for Amount (Rs.) : 0.00 Signature/Date
ONLY

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