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Medical Bill. 2

Prem Prakash Gandhi is submitting an actual OPD medical claim reimbursement form for treatment received from January 2023 to April 2022. The total amount claimed is Rs. 1,57,834. Gandhi received outpatient consultation and treatment from Dr. Bimit K. Jain, an MD in Medicine and DM in Cardiology, at his Heart and Hypertension Clinic on 7 occasions. Gandhi's wife, Saroj Gandhi, is not claiming any medical expenses. The form requires certification from Gandhi and his spouse, as well as approval from the CMO/ACMO and Finance department.

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Harsha Gandhi
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52 views2 pages

Medical Bill. 2

Prem Prakash Gandhi is submitting an actual OPD medical claim reimbursement form for treatment received from January 2023 to April 2022. The total amount claimed is Rs. 1,57,834. Gandhi received outpatient consultation and treatment from Dr. Bimit K. Jain, an MD in Medicine and DM in Cardiology, at his Heart and Hypertension Clinic on 7 occasions. Gandhi's wife, Saroj Gandhi, is not claiming any medical expenses. The form requires certification from Gandhi and his spouse, as well as approval from the CMO/ACMO and Finance department.

Uploaded by

Harsha Gandhi
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLSX, PDF, TXT or read online on Scribd
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NTPC Ltd.

PRMS - ACTUAL OPD Medical Claim for Reimbursement


[As per CHRC No. 869/2019 dated 24.06.2019]
Employee Name: PREM PRAKASH GANDHI Claim Date: 31\03\2023
Emplyoee No.: 021083 Scale/Grade: E-6
Vendor Code: 0001054348 Mobile No.: 9873420216

Patient Name
Name of Doctor's Name Consultation Amount Amount Nature of claim
&

\S. (Consultation
Bill No. Bill dt. Charges, Cost of
N. Relation Hospital / Clinic & Qualification Date Requested Passed
Medicine,
Investigation
Charges, etc.)

12552 10529
07.04.2022 249 1261 07.04.22 07.05.22
PREM PRAKASH
A Heart & Hypertension DR.BIMIT K.JAIN M.D.
GANDHI ( self
1 Clinic (Med.) D.M.(Cardiology )
)
Consultation ,BP,ECG &
126 07.04.22 1000
Sugar FEE

28.05.22 2379 15.06.21 12850


2 ----DO---- ----DO---- ----DO----
Cons FEE 246 15.06.21 1000

15.07.22 3181 15.07.22 15384


3 ----DO---- ----DO---- ----DO----
FEE 314 15.07.22 1000

27.08.22 4271 27.08.22


4 ----DO---- ----DO---- ----DO---- FEE 314 27.08.22 15019 1000

28.09.22 5015 28.09.22 27359


5 ----DO---- ----DO---- ----DO----
FEE 440 28.09.22 1000

29.11.22 6344 29.11.22 26467


6 ----DO---- ----DO---- ----DO----
FEE 537 29.11.22 1000

31.01.23 6344 31.01.23 28904


7 ----DO---- ----DO---- ----DO----
FEE 637 31.01.23 1000
8
Mrs SAROJ
B NIL NIL _ _ _ _ NIL
GANDHIi wife

TOTAL 157834

One lakh ten thousand three hundred seventy three only


Note: All actual bills are to be submitted including the bills of amount claimed on Certification basis during the financial year. Doctor's prescription and cash memos in original should be attached. The
claims as per actuals shall be entertained only once, in the last quarter of the relevant financial year, till 30th April of the next financial year. Extra sheet may be added, if required.

The above claim shall be routed through concerned CMO/ACMO, NTPC before submission of the same to Finance.
Certification by Ex-employee/Spouse:

(i) The statements made in the claim are true to the best of my knowledge and belief.
(ii) I understand that in case it is found that there is misuse of benefits, as claimed above under the scheme, I shall be summarily debarred from the benefits of the Scheme.
ENCLOSURES:

( PREM PRAKASH GANDHI ) (SAROJ GANDHI )


(Signature of Ex-employee) (Signature of spouse)
CMO/ACMO DATE DATE
FINANCE

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