MEDICAL REIMBURSEMENT FORM IN ELECTRONIC FORM.
HERE ARE THE MEDICAL REIMBURSEMENT FORMS NEED TO CLAIM A MEDICAL BILL……..
ANYONE PLEASE TEL ME HOW TO UPLOAD DATA ON THIS SITE IN A PROPER MANNER.
1.	I Jasvir Kaur certify that Mr.Rajinder Singh (father) is a patient of Gangenous Umbilical Omentocoele and undertaking the treatment from Dr. Sethi’s: The Surgical Hospital & Laproscopy Centre, Tagore Nagar, Ludhiana.
2.	I am submitting a Medical Reimbursement bill of amounting Rs. 23,021/- (Twenty Three Thousand & Twenty One Only) Period of treatment is from 18/04/2012 to 20/04/2012= 3days.
3.	I have not received any aid or received from any other source including medical insurance / Accidental insurance.
6.	I hereby declare that the medicines purchased for the treatment of the patient have already been entirely consumed.
7.	I hereby declare that the treatment for which the charge is being claimed is not preferred during the currency of the treatment.
8.	I hereby declare that the treatment for______________________________________ for the above mentioned period has got from________________________________ and further certify that the claim for the above mentioned period from any other dispensary (Except the one stated above) has not been prefferd previously nor will be preferred in future.
9.	It has further that the dependent/ family member viz_______________________in respect of whom treatment medical reimbursement of Rs._____________/- is being claimed is employed in the office of GOVT. HIGH SCHOOL, KHERA FGS which is in PUNJAB STATE, is situated at a distance of 44kms from Chandigarh.
In case the claim of expenditure involves more than six months from the date of expiry of implement, the movement Performa in duplicate is attatched.
Certified that the claims has been checked and round correct in all respects.
I certify that _______________________________________ employed in GOVT. HIGH SCHOOL, KHERA (FATEHGARH SAHIB). The under mentioned medicines prescribed by me in this connection were absolutely essential for the treatment and recovery prevention of serious deterioration in the condition of the patient. The medicines were not stocked in the _________________________________________________________________________________________________________________________ for supply to entitled patients and don’t include proprietary preparations for which cheaper substitute of equal therapeutics value are available nor preparation which are primarily food, toilets or disinfections.
1.	Certified that the facilities for the treatment for which the patient was referred to were not available in the Hospital/ Dispensary.
2.	Certified that the I.P was entitled to medical benefit during the period of treatment.
3.	Certified that the medicines were not available in the stock of Hospital/ Dispensary.
4.	Certified that the medicines prescribed are borne of Pharmocopia.
6.	Certified that the treatment as per prescription was necessary.
7.	Certified that price claimed is reasonable.
4.	Certified that ________________________ is my mother and she is dependent upon me and residing with me.
5.	Certified that the medicines have been purchased by me and consumed by me.
6.	Certified that the basic pay is Rs.18180+5000=23180.
DEMAND NO.	0	5	EDUCATION DEPTT.
1.Certified that necessaries entries have been made in the Medical Re-Imbursement Check Register.
3.Certifed that the Medical bill has been submitted in this office in time.
Pay Rs. (Rs.___________________ only be cash/ cheque/draft account credit as under Rs.___________(Rs._____________only) by adjustment as under.
(Audit register page For Use in Accountant General Office Admitted Rs.	Objected to Rs.