BHARAT HEAVY ELECTRICALS LIMITED

POWER SECTOR EASTERN REGION,PATNA

MEDICAL REIMBURSEMENT CLAIM

NAME : MOHAMMAD HAMEED STAFF NO. : 6115284

DESIGNATION :SUPERVISOR TRAINEE DEPT./DIV. : ERECTION/PS-ER

BASIC PAY : 12300.00 RESIDENT OF BHEL TOWNSHI No
DATE : 27/05/2011 FAMILY LOCATION LUCKNOW
REMARKS:

Out-Door Treatment
Sr. Name Of Consultation Doctors Doctors Lab X-Ray Medicines Other Charges Amount
Patient(s) Details Amount
1 AKEELA BANO 21/02/2011 DR JITENDAR 200.00 0.00 0.00 109.00 309.00
WAHI

Total of I + II 309.00
Net claimed : 309.00
Certified that --
Yes The above particulars are true to the best of my knowledge and belief and the person(s) for whom the medical
expences are claimed is/are wholly dependent on me.
Yes My parent/father/mother is/are normally residing with me and their/his/her income from all sources does not
exceed
Yes My children
Rs 1500/- for whom reimbursement is being claimed fulfil the 'dependency' criteria with regard to age, marital
p.m.
status ,
Yes
My spouse/parents is/are not covered by CGHS an
Yes
The patient(s) covered in this claim is/are not dependent on my spouse
Signature of Controlling Officer
Signature Signature
Name Name MOHAMMAD HAMEED

Designation

Date
Accounts Department
Voucher Number Date Cash Flow Code

Passed for paymernt of

Rs.---------------------------- (Rupees --------------------------------------------------------------------------------------------
Date Accounts Executive

Claim No: CLM/2011/05/0000202