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Medical Reimbursement
I have spent a sum of Rs.
(Rupees)
Dated
Amount
1
2
3
4
Necessary Cash Memos alongwith respective prescription chits, original Discharge Card
and Photo copy of the complete Admission Treatment Chart and Nursing Chart intake output record of the
patient duly attested by the Registrar of the ward/RMO of the Hospital
Are attached. I solemnly declare that the claim is correct and shall be held responsible for
disciplinary action on account of miss-statement or over claiming. It is requested that re-imbursement as
per rules may kindly be made to me. Detail of Medical Treatment expenditure is mentioned in the
attached Non Availability Certificate.
Signature
Applicant Name
Mobile No
Recommendation of the Head of Department
Certified that the applicant is a regular employee of the University of Peshawar and
working as .
under my supervision. The information as furnished above by him/her
are correct. The bill(s) are forwarded for reimbursement.
Head of Department/Institutions
No
Dated
Note
1.
If the bill amount exceeds from Rs.5000/- then two sets of bill (Original + Photocopy)
sets of
bill must be submitted
2.
Dependence certificates in case of father/mother may be attached and photocopy of NIC
of applicant and patient must be attached (dependence certificate form available in
Accounts Section)
Medical Asstt
S.No
is permissible under the rules.
Supdt: Accounts
FOR USE OF AUDIT SECTION
Deputy Treasure
Dated
Rs.
Payees
Dated.
Amount (Rs.)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Total Rs.
(Rupees
)
Registrar/Medical Officer.
Ward No.
Hospital.
Stamp.
Countersigned
Resident Medical Officer
Hospital
Stamp
D E P E N D EN T C ERTI F I C ATE
is working as
Further this patient is neither employed or not Govt. servant /retired employee
and not he /she is getting any pension /Medical coverage from anywhere.
_______________________________________________________________
(Signature of the Head of Department/Section/College and Office Stamp.)