Scribd
Upload
92 views

Domiciliary Claim Form (Employee Id: 382470) Claim No: D0602190382470A003

This document is a domiciliary claim form submitted by Rupak Bhattacharjee, employee ID 382470, for medical expenses incurred from January 30 to February 6, 2019 for eye-related ailments including low vision, blindness, and eye infection. The claim includes prescription and consultation bills totaling 350 rupees. Rupak agrees to submit original documents and acknowledges that providing false information could result in disciplinary action including termination.

Uploaded by

Anonymous Yw2XhfXv
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
92 views

Domiciliary Claim Form (Employee Id: 382470) Claim No: D0602190382470A003

This document is a domiciliary claim form submitted by Rupak Bhattacharjee, employee ID 382470, for medical expenses incurred from January 30 to February 6, 2019 for eye-related ailments including low vision, blindness, and eye infection. The claim includes prescription and consultation bills totaling 350 rupees. Rupak agrees to submit original documents and acknowledges that providing false information could result in disciplinary action including termination.

Uploaded by

Anonymous Yw2XhfXv
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 1

Domiciliary Claim Form(Employee Id :

382470)
Claim No : D0602190382470A003

Employee Details

Employee Id : 382470 Employee name : Rupak Bhattacharjee

EmailId : [email protected] Mobile No : 9477205716

Patient Details

Name of Patient : Rupak Bhattacharjee Gender M

Relationship : Self Age 41

Domiciliary Claim Details

All Hospitalisation claim should be raised within 90 days from the date of discharge

Details of illness/injury : Eye Related Ailments - Low Vision/Blindness/Eye Infection||Low Vision

Name of treating doctor : Rupak Bhattacharjee

Clinic Name : Netrajuoti Clinic PinCode : 700051

Treatment Start Date 30-Jan-2019 Treatment End Date 06-Feb-2019

Medical Documents

Note: Please click on the check box 'Available' to update further details i.e. No.of Bills/Documents & Amount

Document Type Available No. of bills/documetns Amount

Copy of Prescription for Medicine & Investigation 1

Original Pharmacy Bills/Receipts

Original Dr. Consultation Bill with Receipt No. 1 Rs.350

Original Investigation/Lab Bills/Receipts & Copy of Reports

Case Summary/ X-Ray Report (for Dental Treatments)

Any Other Document

Total no. of documents & claimed amount 2 Rs.350

I will retain the scanned copies & submit the hard copies of all Original Medical bills and Documents with this claim form:

On Branch Address

06-Feb-2019 HIS Helpdesk - KOLKATA, BHUBANESWAR, HIS Helpdesk, Tata Consultancy Services Ltd., 1W-16, 1st Floor, Delta Park
PATNA, JAMSHEDPUR, GUWAHATI Eden, Salt Lake Electronics Complex, Kolkata ? 700091.

DISCLAIMER/TERMS OF AGREEMENT

All information provided in this claim form is true and correct. If it is found to be false and/or if it is proved that claim documents are manipulated then, I understand
and agree that TCS can initiate appropriate disciplinary action which may also lead to termination of my employment with TCS.

Date Employee Signature

Date of Submission

You might also like