HUALI ELECTRICITY SUPPLY COMPANY LIMITED

I
SANCIION,CUM.VOL]CHER FORII FOR CLAII4ING REFUND OF [,IEDICAL EXPENSES

2. office in which Empioyed

3,

5 Full Resrdential address

6. Name ofthe patient &his/her reationship

Noter In the case ofchildren state age also

Place at which panent fell ill

Nature oflllness and its duraiion

9, Details for the Amount claimed

10. Total amoont claimed

11

DECLARATION
I hereby declare that the statements in this application are true lo the best of my
knowledge and belief and that the person for whom medlcal expenses were included Is
a member of my iannly and is wholly dependent on me.

Offlce

Signature &designation
of Sanctioning authority
Foi use in Divisional Hiohe. officer. B.R. NO.:

Pa$ed lor Fs....... .. .. . .. . ., ... .. ..,/ (in words.. ... ......... . ...... ............
Please pay oy .heqLe/D, D, tor Rs....................
...... ..in favour of . . .. ... .

Asst. Accounts olficer,

Note: Separate form should for each patient

 Beinq reimbursement of l'ledical erpenses.

An:estation wh€rev€r necessary

Siqnature a.d desiqnatio.

For lse in Dvnl/Hiqher Officer.

cash Book Voucher No.... . . ....... .

Pald Rs.................................... ..,...... Dt..,,..,, ...,,,.,Charged off Rs.... .......

cashier Cash Omcer.

ESSENTIALITY CERTIFICATE

I certlfy that ME/Mrllviss/ Himself .....-..............

..-....,...Hospitarmy consulting room, and the onder mentioned medlcines prescribed by

me in this connection were essential for the recovery of the Patient. The prevention of
Senous deterioration ln the condiiion Enclosed tne Descriptions the medicines are not
stocked in the My Hospltal and do not incltide proprietary preparations for supply to
pdvate patients, For ,..,.,,.....................-................, whi.h cheaper subsiances of equai
therepoutic value are avallable nol reparations whrch are primarily ioods, toilets or

signature & Designation of

Authorized l.4edical Atteodant

Signature of the Medical Officerin-chaBe

Ofthe case at the Hospital-