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ANNEXURE - C MEDICAL REIMBURSEMENT CLAIM FORM FOR OUTDOOR TREATMENT Name of Employee 2. Designation Reg. No. Salary Basic Pay DA /Pension as on 01-04-------- Place of Duty 6. Name of Patient Relationship with Employee 8. Age Reimbursement claimed under Tick relevant box Treatment from RMP as per Para 2. 1. 0 10. Nature of illness 11. Name of Doctor/Hospital 12. Details of claim attach prescription vouchers etc* in duplicate Voucher No* Amount Consultation Diagnostics/Tests Medicines Appliances Special treatment e*g* Physiotherapy Yoga etc* Others Total Rupees ------------------------------------------------------ Declaration I hereby declare that the statements given in application are true to the best of my knowledge and belief and that the person for which medical expenses are incurred is wholly dependent on me. Name of Patient Relationship with Employee 8. Age Reimbursement claimed under Tick relevant box Treatment from RMP as per Para 2. 1. 0 10. Nature of illness 11. Name of Doctor/Hospital 12. Details of claim attach prescription vouchers etc* in duplicate Voucher No* Amount Consultation Diagnostics/Tests Medicines Appliances Special treatment e*g* Physiotherapy Yoga etc* Others Total Rupees ------------------------------------------------------ Declaration I hereby declare that the statements given in application are true to the best of my knowledge and belief and that the person for which medical expenses are incurred is wholly dependent on me.

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