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    Medical Reinbursment Form PDF

    Uploaded by

    Tariq Muhammad
    This document is a medical expense reimbursement form for an employee to claim reimbursement for medical expenses incurred by themselves, their spouse, children, or parents. The form collects the employee's name, department, employee number, grade, location, doctor/institution details, and a breakdown of expenses including consultation fees, lab charges, hospitalization charges, cost of medicines, and other expenses. It requires the claimant's signature and date as well as verification signatures from HR and the Chief Executive.

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    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd

    Medical Reinbursment Form PDF

    Uploaded by

    Tariq Muhammad
    16 views1 page
    This document is a medical expense reimbursement form for an employee to claim reimbursement for medical expenses incurred by themselves, their spouse, children, or parents. The form collects the employee's name, department, employee number, grade, location, doctor/institution details, and a breakdown of expenses including consultation fees, lab charges, hospitalization charges, cost of medicines, and other expenses. It requires the claimant's signature and date as well as verification signatures from HR and the Chief Executive.

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    medical reinbursment form.pdf

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    This document is a medical expense reimbursement form for an employee to claim reimbursement for medical expenses incurred by themselves, their spouse, children, or parents. The form collects the employee's name, department, employee number, grade, location, doctor/institution details, and a breakdown of expenses including consultation fees, lab charges, hospitalization charges, cost of medicines, and other expenses. It requires the claimant's signature and date as well as verification signatures from HR and the Chief Executive.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    16 views1 page

    Medical Reinbursment Form PDF

    Uploaded by

    Tariq Muhammad
    This document is a medical expense reimbursement form for an employee to claim reimbursement for medical expenses incurred by themselves, their spouse, children, or parents. The form collects the employee's name, department, employee number, grade, location, doctor/institution details, and a breakdown of expenses including consultation fees, lab charges, hospitalization charges, cost of medicines, and other expenses. It requires the claimant's signature and date as well as verification signatures from HR and the Chief Executive.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    MEDICAL EXPENSE REIMBURSEMENT

    Name:

    ____________________________________________________ Department: _____________________________________

    Employee # __________________________________________________ Grade: __________________________________________


    Location: ____________________________________________________ _________________________________________________
    Name of Doctor/Institution: ____________________________________ _________________________________________________

    Medical Expenses Incurred by:


    Myself

    ____________________________________________________

    Spouse ____________________________________________________
    Children ____________________________________________________
    Parents ____________________________________________________

    1.

    Consultation Fee Rs. ___________________________________

    2.

    Lab charges Rs. ______________________________________

    3.

    Hospitalization Charges Rs. _____________________________

    4.

    Cost of Medicines Rs. __________________________________

    5.

    Others (Please Specify) ________________________________

    Amount in words

    Claimant's Signature: _________________________________________ Date: ___________________________________________


    Verified by(HR Dept): _________________________________________ Date: ___________________________________________
    Chief Executive: ______________________________________________

    Date: __________________________________________

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