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  • Medical Claim Form: If The Claim Amount Is More Then Rs 800 Please Attach Prescription of Doctor / Physician

    Загружено:

    Zaheer Ahmed Tanoli
    22 просмотров1 страница
    This document is a medical claim form for an employee of Crystal Construction Pvt Ltd. It requests information such as the employee and patient's name and relationship, medical expenses incurred with breakdown of costs, hospital information, total room charges, entitlements and deductions, and requires signatures for approval. It notes that a doctor's prescription is needed if the claim amount is more than Rs. 800.

    Исходное описание:

    TRSCV

    Оригинальное название

    Medical Claim Form

    Авторское право

    © Attribution Non-Commercial (BY-NC)

    Доступные форматы

    PDF, TXT или читайте онлайн в Scribd

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    This document is a medical claim form for an employee of Crystal Construction Pvt Ltd. It requests information such as the employee and patient's name and relationship, medical expenses incurred with breakdown of costs, hospital information, total room charges, entitlements and deductions, and requires signatures for approval. It notes that a doctor's prescription is needed if the claim amount is more than Rs. 800.

    Авторское право:

    Attribution Non-Commercial (BY-NC)
    Скачайте в формате PDF, TXT или читайте онлайн в Scribd
    Отметить как неприемлемый контент
    22 просмотров1 страница

    Medical Claim Form: If The Claim Amount Is More Then Rs 800 Please Attach Prescription of Doctor / Physician

    Загружено:

    Zaheer Ahmed Tanoli
    This document is a medical claim form for an employee of Crystal Construction Pvt Ltd. It requests information such as the employee and patient's name and relationship, medical expenses incurred with breakdown of costs, hospital information, total room charges, entitlements and deductions, and requires signatures for approval. It notes that a doctor's prescription is needed if the claim amount is more than Rs. 800.

    Авторское право:

    Attribution Non-Commercial (BY-NC)
    Скачайте в формате PDF, TXT или читайте онлайн в Scribd
    Отметить как неприемлемый контент
    из 1

    CRYSTALCONSTRUCTIONPvtLtd.

    MEDICALCLAIMFORM

    OUTPATIENTDEPARTMENT HOS PITALIZATION

    NameofEmployee Division BankAccount# MedicalExpensesIncurredBy: MySelf 1.ConsultationFee 2.LabCharges 3.Hospitalization 4.CostOfMedicine 5.Other(Specify) Total AmountinWords: Rs Rs Rs Rs Rs Rs Rupees: Spouse

    Empolyee# Location Branch Children Parents

    Note
    Iftheclaim amountismorethen Rs800pleaseattach Prescriptionof Doctor/Physician

    PATIENTINFORMATION NameofPatient RelationwithEmployee

    HOSPITALINFORMATION HospitalName Doctor'sPhysicianName

    HospitalName Reason Hospital&Doctor'sContactInformation BILLINGINFORMATION Days Total RoomLimit

    Entitlements RoomEntitlements TotalBill TotalDeductions TotalPayable AmountinWord

    Rs

    Deductions(IfAny)

    Medicine'snotCovered

    Adcanve(IfReceived) CosmaticTreatment

    (Pleaseattachallreleventprescriptions&bills)

    SIGNATURES/APPROVALS Claimant'sSignatures HumanResourcesDivision


    (Regional/HeadOffice)

    Date Date Date FOROFFICEUSEONLY

    Comp&Benefits

    Entitelment

    Claimed

    Balance

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