Scribd
Upload
22 views1 page

Medical Ret Medical

This document is an application form for claiming reimbursement of medical expenses for retired officials, specifically for Shri. Naidu T M for his wife, T Ramadevi. The form includes details such as consultation fees, hospital expenses, and a declaration of dependency. It also outlines important instructions regarding the submission of the claim and the necessity for prior approval for treatments outside Bangalore.

Uploaded by

ksc.education
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
22 views1 page

Medical Ret Medical

This document is an application form for claiming reimbursement of medical expenses for retired officials, specifically for Shri. Naidu T M for his wife, T Ramadevi. The form includes details such as consultation fees, hospital expenses, and a declaration of dependency. It also outlines important instructions regarding the submission of the claim and the necessity for prior approval for treatments outside Bangalore.

Uploaded by

ksc.education
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
You are on page 1/ 1

BILL No: ADA

DATE: BANGALORE
Form of Application for Claiming Reimbursement of Medical Expenses
(Retired Officials)
(N.B. : Separate form should be used for each patient)
To be read carefully before filling
1. Complete all Columns below. 3. Enclosures should be in original only.
2. Incomplete claim form will be rejected. 4. If not claimed within 3 months, claim will be forfeited.
5. Prior approval of Admin is required for taking treatment outside Bangalore.
Application No. 50386 Application date 23/05/2025
Staff Code No. 70 Name Shri. Naidu T M
Designation(at the time of Sc/Engr G Email Id tmnaidu4@gmail.com
Retirement)
Name of the Patient T Ramadevi Relationship Wife

Dependency Cleared YES Age 63 Years 10 Month


Consultation Fees Name of the Doctor
Date(s) of Consultation No.(s) of Consultation
Specialist Consultation 350.00 Name of the Specialist Dr Udaykumar S B
Fees
No.(s) of Consultation 1 Date(s) of Consultation 08/05/2025
Hospital Expenses Nursing Home/Hospital
name
Period of Stay Cost of Medicines 419.00
Laboratory Charges Others
Total amount claimed 769.00 List of enclosures 3

DECLARATION TO BE SIGNED BY THE RETIRED OFFICIAL


I hereby declare that the statements in the application are true and that the person for whom medical expenses incurred
is wholly dependent on me.
Date: 23/05/2025 Signature:

FOR OFFICE USE ONLY


PASS ORDER Counter signed RECEIPT
Bill passed for Rs ........................... ( For Admin's use) Received Rs ...................................
( Rupees ............................. .........................................................
............................................)

Sr.ASST/AO SAO-II/SAO-I AO/SAO-II Dated STAMP

You might also like