Form No. MED-BIL-01

/ OIL AND NATURAL GAS CORPORATION LTD

MEDICAL REIMBURSEMENT BILL

CPF No: /
/ Name: / Bill Code:
Designation: /
/ Section/Site: / ______Org. Unit:______Location:______
Date of joining ONGC:
(for regular employee) /
/ Date of Retirement
(for retired employee) / Bank A/C No.: ………………………………....
Basic Pay
/ SP Rs.
/ PP Rs.
/ DA Rs. / Bank Name: ……………………………………
SlNo / Name of the patient / Age / Relation-ship / Nature of illness / Name of Doctor / Specialist / Indoor / Outdoor (struck off whichever is not applicable) / Amount claimed / For Office Use only
Particulars of Cash Memo / Receipt
No. Date / Passed for / Deduction particulars
Amount Claimed (in words) Total
Certified that – (a) the claim is as per actual expenditure incurred. (b) the person for whom expenses have been incurred is dependent on me.
Date: Signature of employee
Sanctioned subject to admissibility & verification by M.O. or Medical section and pre-audit.
Date: (Signature)
Controlling Officer / Claim verified and recommended for payment of Rs.------
Date: ( Signature )
I/C-Medical Section / Entered in SWAN
Date: (Signature)
Authorized officer- HR/ER
/ Passed for payment of Rs.
(Rupees______
______)
Date: (Signature)
Finance Officer

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Details of enclosed Cash Memos / Receipts /

INSTRUCTIONS

§  Each claim shall be supported by copy of doctor’s prescription, original cash memo, bill, money receipts duly countersigned by the concerned employee.
§  Particulars of expenses on hospitalisation may be shown separately along with relevant documents like discharge certificate, receipts, cash memo, bill etc.
§  This form can be used for whole family and also for Inpatient and Outpatient Bills.
§  Medical reimbursement claims for a particular month may be submitted in the following month.
§  All medical reimbursement claims including out door treatment upto Rs.2500/- shall be routed through Medical Services and HE/ER. After entering the details of the claim in System (SWAN), the authorized officer in HR/ER will countersign the medical claim and forward to finance for payment.
Name of patient / Cash Memo/Receipt
No. Date / Amount
(Rs.) / Sub-Total for each
Individual (Rs.)
Total