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Page last modified on : 11-06-2019
V.O.CHIDAMBARANAR PORT TRUST - CLAIM FORM FOR MEDICAL REIMBURSEMENT BILLS IN RESPECT OF WORKING EMPLOYEES
Department
*
:
Please select
Administration
Finance
Medical
Traffic
Mechanincal
Civil
Marine
EDP
Vigilance
*
Name of the Employee
*
:
*
Email ID
*
:
*
*
Designation
*
:
*
Employee No
*
:
*
Medical ID No
*
:
*
Name of the Patient
*
:
*
Relationship with Employee
Self or Spouse
Dependent
In case of dependent of the Employee
a) Whether name has been enrolled in the Medical Identity Card :
*
b) Date of Birth and Age of the Dependent (Copy of Medical ID card failing which details available in medisoft system to be enclosed) :
*
c) Below 25 years/Above 25 years :
*
d) Whether the monthly income is limited as per the CS (MA) rules i.e. Rs.3900/-+ amount of the Dearness relief on the basic Pension of Rs.3900/- as per pay revision orders for Port. :
*
Name & place of the Hospital
*
:
*
Period of Treatment
*
:
*
Hospital Type :
Referral Hospital
Non Referral Hospital
In case the treatment was at referral Hospital, whether the treatment was recommended by the Medical Department
*
:
*
In case the treatment was at Non referral Hospital, whether intimation was given by the Employee about the present treatment taken :
Yes
No
If Yes, date of intimation & Copy of the Intimation to be enclosed
*
:
*
Whether the Hospitalisation was due to Emergency situation or Normal
*
:
*
Total Bill Amount claimed
Rs
*
:
*
Rupees in words
*
:
*
Enclosures
a) No of Original Bills
b) Medical reports
c) Certificates(A&B)
d) Copy of Medical ID card or details in medisoft system
e) Copy of the reference letter
Declaration Form
I also declare that the information furnished above is true to the best of my knowledge and belief.
Date
*
:
*
Word Verification
*
:
*
Type the characters you see in the picture below.
* - Please fill out all the required fields before submitting the form.