Medical Profroma - 13 - 07 21

ALLAMA IQBAL OPEN UNIVERSITY
(Establishment Section)
PROFORMA FOR APPLYING INDOOR MEDICAL TREATMENT CHARGES FOR

REIMBURSEMENT
Please fill out the column given below for reimbursement of medical treatment charges.
1 Name & Designation of Employee:
2 Department:
3 Nature of Job (Regular/Contract/Deputation etc)
4 Contact No.:
5 Status of employee (Serving/retired etc)
6 Name of Patient:
7 Relationship of patient with employee
8 Status of patient: whether the patient is
Serving/retired employee of government/semi
Govt/Autonomous department OR is wholly
dependent and is residing with employee (
9 Age of the patient
10 CNIC/ Form ‘B’ of the patient OR FRC issued by (Copy attached)
Nadra
11 Date of Admission/Discharge:
12 Name & Status of Hospital:
(Govt/ Private/ Trust)
13 Reason being admitted in private hospital (Attached documentary
justification)
14 Nature of treatment (indoor/Emergency) (Relevant proforma is available at
AIOU website)
15 Specify disease for which reimbursement claim is
being submitted
16 Amount being claimed for reimbursement: (Attach original vouchers with
paid stamps, prescription,
admission & discharge slip duly
attested by concerned doctor)
17 Details of previous sanctioned amount/ advance (Copy attached)
payment where reimbursement has been
claimed/released for same disease:
Certification/Declaration:
a) The patient (Name of Patient/ Relation) for whom hospitalization charges are claimed, is solely
dependent and residing with me.
b) The above named patient is not serving/retired from any other Government/Semi
Government/Autonomies Organization.
c) The reimbursement of hospitalization expenses or part thereof or any financial relief/assistance
has not been or shall not be claimed by me/my any other member of family from any source
(Govt./Semi Govt./private) other then Allama Iqbal Open University.
d) I hereby undertake that the information mentioned above is correct & true. In case of any wrong
statement I shall be held responsible and liable for proceedings under E&D rules. Moreover, amount
reimbursed be recovered from my salary/ pension.
___________________
__________________________ _
(Name, Designation, Department Signature/ Stamp of
& Signature of the employee)
Head of the Department
____________
Date: ______________ Registrar
PROFORMA FOR APPLYING PROLONGED & EXPENSIVE OUTDOOR MEDICAL

TREATMENT CHARGES FOR REIMBURSEMENT
Please fill out the column given below for reimbursement of medical treatment charges.
1 Name & Designation of Employee:
2 Department:
3 Nature of Job (Regular/Contract/Deputation etc)
4 Contact No.:
5 Name of Patient:
6 Relationship of patient with employee
7 Status of patient: whether the patient is
Serving/retired employee of government/semi
Govt/Autonomous department OR is wholly
dependent and is residing with employee (
8 Age of the patient
9 CNIC/ Form ‘B’ of the patient OR FRC issued by (Copy attached)
Nadra
10 Specify disease
11 Claim period
12 Amount being claimed for reimbursement: (Attach attested original vouchers
with paid stamp along-with the
advise of Authorized Medical
Attended (advise is not exceeding
last six months)
Certification/Declaration:
a) The patient (Name of Patient/ Relation) for whom medicine charges are claimed, is solely
dependent and residing with me.
b) The above named patient is not serving/retired from any other Government/Semi
Government/Autonomies Organization.
c) The reimbursement of medicine charges or part thereof or any financial relief/assistance has not
been or shall not be claimed by me/my any other member of family from any source (Govt./Semi
Govt./private) other then Allama Iqbal Open University.
d) I hereby undertake that the information mentioned above is correct & true. In case of any wrong
statement I shall be held responsible and liable for proceedings under E&D rules. Moreover, amount
reimbursed be recovered from my salary/ pension.
___________________
__________________________ _
(Name, Designation, Department Signature/ Stamp of
& Signature of the employee)
Head of the Department
____________
Date: ______________ Registrar
*****
CERTIFICATE
This is to certify that:
(a) Cost of medical attendance of treatment charged for in the bill was
necessary for the rest
(b)oration of health of the patient whose specimen signatures are
given below and also that:
(c) The medicines which were purchased by the patient as per Cash
Memo (s) attached and detailed below, from the market were not
available in the hospital and were essentially required for the
treatment and restoration of health of the patient:
Sr. No. Cash-memo No. & Medicines purchased from Amount

Date
Name & Signature of the Patient Signature of

MS/Registrar/MO
Please affix rubber stamp of the
Hospital.

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ALLAMA IQBAL OPEN UNIVERSITY

PROFORMA FOR APPLYING INDOOR MEDICAL TREATMENT CHARGES FOR

PROFORMA FOR APPLYING PROLONGED & EXPENSIVE OUTDOOR MEDICAL

Sr. No. Cash-memo No. & Medicines purchased from Amount

Name & Signature of the Patient Signature of

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