MEDICAL REIMBURSEMENT (Supported by BILLS) HRMS APPLICATION PARTICULARS

EMPLOYEE DETAILS PF Index No Name Request No Bank Account No. Cadre Date of Joining Cost Center 5535301 Kiranmai Chundi Employee ID/PERNR Branch / Office Request Date Designation Mobile No Intercom No. Department (fill manually, if required): APPROVER DETAILS 1. Patlawath Bhadru 2. CLAIM DETAILS Type of Reimbursement: Nature of illness: Treatment Taken By: KIRANMAI CHUNDI Period of Treatment From : 14.06.2013 Name of Doctor: K SUPRAJA Name of Hospital: Sarada Maternity Hospital Hospitalisation From: 14.06.2013 HOSPITALISATION EXP. Caesarean Age: 025 To: 17.06.2013 Qualification of Doctor: M.B.B.S.,D.G.O.,Diab., Whether Hospital Empanelled ?: No To: 17.06.2013 Days: 0003 Relationship: SELF 3. 00553530 Vedayapalem

For SELF

MDO0000601899
31583744988 Clerical 15.12.2010 VEDAYAPALEM

26.06.2013
Asst. (Banking) 9701256277

Address of Hospital: Sarada Maternity Hospital,Near Amma Auction Hall, Pogathota ,Nellore

Major Head-Wise Summary of Expenditure incurred Classification of Expenses

COST OF MEDICINE BED CHARGES-EXCL. DIET CHARGES ANESTHESIA CHARGES SURGEON#S CHARGES OPERATION CHARGES/PACKAGE FOR OPERATION/TREATMENT NURSING CHARGES OTHER EXPENSES

Amount (Rs.)
6960.00 3000.00 2500.00 8500.00 2500.00 500.00 1600.00

TOTAL EXPENSES
Total Bill Amount: Total Amount Claimed: 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 polity or under my claim in respect of an accident or from any other source. The expenses as detailed above were actually incurred by me for family members wholly dependent on me. 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. My parents are not having the monthly income exceeding the limits prescribed by the Bank. 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. 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.NOT WORKI during the calendar/financial year from his/her employer. 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 with income over Rs. 500/- per month, male children above 24 years married children. In case of Dental Treatment (applicable in case of officers only) necessary prior approval from the competent authority has been obtained.

Rs. 25560.00 Rs. 25560.00

Amount of Advance Taken if any:

Rs. 0.00

I Further certify that:

* * * * * * * * *

Employee ID/PERNR : 00553530

Request No : MDO0000601899 Page No.1 of 3

Name: Kiranmai Chundi

The Bills, receipts, supporting vouchers, prescription etc, and copy of the approval/s, where required, are enclosed with printed copy of this claim.

Date:26.06.2013

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. 25560.00 ( twenty five thousand five hundred sixty rupees only).

Date: For Office Use

Head of the Dept./Branch Manager

Sanctioned for payment Rs.__________________(Rupees_________________________________________________ ______________________________________________________only) by debit to appropriate Charges BGL account. Of the total Sanctioned amount Amount Taxable Amount Non-Taxable@@@ Remarks: Rs.

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. Please do not include exemption amount of Rs 15000/- here, system will automatically give exemption for that.

MAJOR HEAD WISE DETAILS OF EXPENSES INCURRED

ANNEXURE

classification of expenses
COST OF MEDICINE COST OF MEDICINE COST OF MEDICINE COST OF MEDICINE COST OF MEDICINE COST OF MEDICINE COST OF MEDICINE COST OF MEDICINE COST OF MEDICINE COST OF MEDICINE COST OF MEDICINE COST OF MEDICINE BED CHARGES-EXCL. DIET CHARGES ANESTHESIA CHARGES SURGEON#S CHARGES OPERATION CHARGES/PACKAGE FOR OPERATION/TREATMENT NURSING CHARGES OTHER EXPENSES

Name of the Doctor/Chemist/Lab/Hospital Bill/Cash Memo No.

ANU MEDICALS PADMAVATHI MEDICAL & FANCY ANU MEDICALS ANU MEDICALS ANU MEDICALS ANU MEDICALS ANU MEDICALS ANU MEDICALS ANU MEDICALS ANU MEDICALS ANU MEDICALS ANU MEDICALS SARADA MATERNITY HOSPITAL SARADA MATERNITY HOSPITAL SARADA MATERNITY HOSPITAL SARADA MATERNITY HOSPITAL SARADA MATERNITY HOSPITAL SIRISHA SCAN & X-RAY CENTRE 467 93 458 459 74 76 77 78 79 80 81 84 328 328 328 328 328 64

Dated
17.06.2013 17.06.2013 16.06.2013 16.06.2013 15.06.2013 15.06.2013 15.06.2013 15.06.2013 15.06.2013 15.06.2013 15.06.2013 15.06.2013 17.06.2013 17.06.2013 17.06.2013 17.06.2013 17.06.2013 14.06.2013

Amount (Rs.)
451.00 303.00 378.00 395.00 465.00 1471.00 1375.00 835.00 307.00 240.00 118.00 622.00 3000.00 2500.00 8500.00 2500.00 500.00 500.00

Employee ID/PERNR : 00553530

Request No : MDO0000601899 Page No.2 of 3

Name: Kiranmai Chundi

OTHER EXPENSES OTHER EXPENSES

V.N. DIAGNOSTICS & X-RAY SARADA MATERNITY HOSPITAL

119 328

15.06.2013 17.06.2013

500.00 600.00

Total

25560.00

Employee ID/PERNR : 00553530

Request No : MDO0000601899 Page No.3 of 3

Name: Kiranmai Chundi