Claim Form for Reimbursement of Medical Expenses

Contributory Scheme for Post Retirement Medical Facilities for Employee

CLAIM FORM FOR REIMBURSEMENT OF MEDICAL EXPENSES

INCURRED BY THE RETIRED EMPLOYEE/ SPOUSE

Registration card No. ______Vendor Code……………………….

Name & Grade of the Employee who has retired / Emp. No. / Last Pay Drawn

Present Address at which : IFSC Code:______

The Cheque is to be sent/ECS A/c No. :

DETAILS OF AMOUNT CLAIMED
NON HOSPITALISATION CASES AMOUNT
Patient’s Name&
Relation / Name of Hospital/
Doctor / Doctor’s
Qualification-ion / Consultation
Date / Cash
Memo
No. / Consultation
charges / Cost of Medicines / Investigations
Charges
1 / 2 / 3
TOTAL. 1+2+3 in Rs.
DETAILS OF AMOUNT DISALLOWED
Reasons Amount
1.
2.
3.
4. AO/Sr.A.O.

Date: ______(Signature of the retired employee/spouse)

PRMS Beneficiary’s CONTACT NO: MOB: ...... Landline: ………………

PRMS Beneficiary’s EMAIL ID: ......

(TO BE FILLED IN CASE OF HOSPITALISATION)

DETAILS OF AMOUNT CLAIMED
HOSPITALISATION CASES AMOUNT
Patient’s Name &
Relation / Name of Hospital / ACCOMMODATION CHARGES
(1) / Cost of
Medicine
(Rs.)
(2) / Surgical of
Confinement
Charges (Rs.)
(3)
From
Date / To
Date / Rate/
Day / Amount
(Rs.)
TOTAL. 1+2+3 in Rs.
DETAILS OF AMOUNT DISALLOWED
Reasons Amount
1.
2.
3.
4. AO/Sr.A.O.

NOTE:

1)  Doctor’s Prescription and cash memos in original should be attached.

2)  Receipts for amount claimed should be enclosed.

3)  Separate claims should be prepared for each patient and each spell of treatment.

(To be certified by the Retire employee/ Spouse)

i)  The statements made in the claim are true to the best of my knowledge and belief.

ii)  I am a member of Contributory Scheme for Post Retirement Medical Facilities, in case of death of serving employee and my Medical Card is valid since______.

iii)  I continue to fulfill the conditions of eligibility for awaiting the benefits under the scheme.

iv)  The Medical expenses were incurred for self.

v)  I fully understand that Company may refuse/ terminate my membership of the scheme at any time without any notice and without assigning any reasons.

Date: ______(Signature of the retired employee/spouse)

PRMS Beneficiary’s CONTACT NO: MOB: ...... Landline: ………………

PRMS Beneficiary’s EMAIL ID: ......