UNIVERSITY OF PESHAWAR

MEDICAL REIMBURSEMENT FORM

To
The Treasurer,
University of Peshawar.
Subject:

Medical Reimbursement
I have spent a sum of Rs.

(Rupees)

on the treatment of my Self/wife/Son/Daughter/Father/Mother as per following

breakdown:S.No.

Cash Memo No.

Dated

Amount

1
2
3
4
Necessary Cash Memos alongwith respective prescription chits, original Discharge Card
and Photo copy of the complete Admission Treatment Chart and Nursing Chart intake output record of the
patient duly attested by the Registrar of the ward/RMO of the Hospital
Are attached. I solemnly declare that the claim is correct and shall be held responsible for
disciplinary action on account of miss-statement or over claiming. It is requested that re-imbursement as
per rules may kindly be made to me. Detail of Medical Treatment expenditure is mentioned in the
attached Non Availability Certificate.
Signature
Applicant Name
Mobile No
Recommendation of the Head of Department
Certified that the applicant is a regular employee of the University of Peshawar and
working as .
under my supervision. The information as furnished above by him/her
are correct. The bill(s) are forwarded for reimbursement.
Head of Department/Institutions
No
Dated
Note
1.
If the bill amount exceeds from Rs.5000/- then two sets of bill (Original + Photocopy)
sets of
bill must be submitted
2.
Dependence certificates in case of father/mother may be attached and photocopy of NIC
of applicant and patient must be attached (dependence certificate form available in
Accounts Section)

FOR USE OF ACCOUNTS SECTION

Register No
Page No
The bill(s) have been checked. A sum of Rs

Medical Asstt

S.No
is permissible under the rules.

Supdt: Accounts
FOR USE OF AUDIT SECTION

Deputy Treasure

Received Cheque No.

Signatur

Dated

Rs.

Payees

eNON AVAILABILITY CERTIFICATE

It is certified that the medicines whose cost is being claimed for re-imburse
were prescribed for the treatment of the under mentioned patient. Due to nonavailability of the medicine or their substitute in the store of this Hospital, purchase
of these medicines from the market was necessary.
Name of Patient:
Disease:
Father/Mother/Wife/Son/Daughter of:
Dependent on :
Designation
Deptt:/College/Section
Details of purchased medicines cash memos are as under :S.No.

Cash Memo No.

Dated.

Amount (Rs.)

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Total Rs.
(Rupees

)
Registrar/Medical Officer.
Ward No.
Hospital.
Stamp.

Countersigned
Resident Medical Officer
Hospital

Stamp

This is to certify that Mr / Ms

D E P E N D EN T C ERTI F I C ATE

is working as

__________________in this office. He / She is a permanent employee of the

Universit y of Peshawar. His / her Father / Mother /Husband /Wife / Son/ Daughter namely
_____________________ is living with him / h e r and is fully dependent on hi m/ h e r
i nc l ud i ng me d i ca l tr e at me nt . H e /S he h as no ot he r pe rs on fo r h is /h er me d i c a l
care.

Further this patient is neither employed or not Govt. servant /retired employee
and not he /she is getting any pension /Medical coverage from anywhere.

_______________________________________________________________
(Signature of the Head of Department/Section/College and Office Stamp.)