INDIAN INSTITUTE OF TECHNOLOGY DELHI Medical Reimbursement Form

INDIAN INSTITUTE OF TECHNOLOGY DELHI
Medical Reimbursement Form
(Separate form should be filled for each patient)
Insurance status ( yes/ no ) …… If yes, Insurance policy number: ………………….

Date / duration of validity: …………………………………………

Employee Details
Name of the Employee

Employee’s Code No.

Contact phone Number: ………………..…

Deptt./ Centre/ Section/ Unit/ Cell

Residential postal address

Designation of the Employee

Pay Scale

Bank Account No.(SBI/Canara
Bank)

If Retire employee: please submit following details also

Month & Year of retirement : …………………………Medical I.D. no.- ……………………

Adopted Post Retirement Medical Scheme ( PRMS) ( yes/ no ) ……..…

Patient Details (Attach photocopy of valid medical booklet front page)

Name of the Patient

Medical Booklet Code
No.

His/her Relationship to the employee

In the case of children, state age, date of birth and marital status

Nature of illness and its duration

Place at which the patient fell ill

DECLARATION TO BE SIGNED BY THE EMPLOYEE OF THE INSTITUTE
I hereby declare that the statements in this application are true to the best of my knowledge and that Mr./Mrs./Miss. _____________________ (Relation) ____________ for Whose medical treatment expenses were incurred is wholly dependent upon me. Total Amount Claimed: ………………………………….
(Employee Signature with date)
Page 1.

1. For Investigations

(Attach Original Bills along with photocopies of authorized doctor advice & arrange serially)

If space is insufficient, kindly attached similar format page.

Slo.N. Date

Original Bills / Cash Memo Number

Name of Centre / Lab / Hospital

Name of Investigation

Amount ( Rupees )

1

2

3

Subtotal Amount Claimed for investigations: ………………………………….

2. For Medicines

(Attach Original Bills along with photocopies of authorized doctor advice& arrange serially)

If space is insufficient, kindly attached similar format page.

Sl.N Date o.

Original Bills / Cash Memo
Number

Name of Chemist / Pharmacy
shop

Name of Medicines (write in
readable handwriting)

Quantit y

Amount ( in rupees )

1

2
Subtotal Amount Claimed for Medicines: ………………………………….
Page 2.

3. Amount claimed for other

(Attach Original Bills along with photocopies of authorized doctor advice& arrange serially)

If space is insufficient, kindly attached similar format page.

Sl.N Date o.

Amount ( in rupees )

Amount claimed

Room

a rent

Consult

b

ation

Operation /
Procedure expenditu
re
c

Other ( specify)
d

Subtotal Amount Claimed for others: ………………………………….
Employee’s Name …………………….……

(Employee Signature with date)

FOR IIT HOSPITAL USE ONLY
Employee’s Code No. ………………
Scrutinized/ Checked & Entered by : Name & Stamp ………………………………..

Signature & date: ………………………………………………………

Sign & stamp of Ayurveda / Homeopathy / Unani Doctor
(Cross non admissible)

Sign & stamp of Doctor Incharge Reimbursement

Sign & stamp of Head Hospital Services
Page 3.

For account section use only

Checked & Passed for Rs._______________ (Rupees ____________________________) And credited to Account No._____________ of Shri / Smt._______________________ in the State Bank of India, IIT Branch / Canara Bank, IIT Extension Counter on _____

Dealing assistant

Accountant Page 4.

Assistant Registrar (Accounts)

CERTIFICATE FROM THE TREATING HOSPITAL / DOCTOR
(For Indoor/Admitted Patients , Ayurveda , Unani & Homeopathy treatment)
Certified that Shri/Smt. ……………………………………………………. son/daughter/wife of Shri/Smt. ……………………………………of Indian Institute of Technology Delhi was under my treatment (diagnosis) as an Indoor/outdoor patient at ……………………………………. Hospital Period of Hospitalization/ OPD : From _________________ To ____________________
All the bills / cash memos have been signed by me
Signature & Name of Designation of treating Physician/Surgeon Please put your Stamp in this space:
(Counter Signature & Stamp of Medical Superintendent of the Treating Hospital)
For admitted Patients, attached photocopies of discharge sheet & other relevant documents with original detail bills
Page 5.