sbi medical bill

MEDICAL REIMBURSEMENT (Supported by BILLS)

HRMSAPPLICATION PARTICULARS

EMPLOYEE DETAILS For SELF

PF Index No 5535301 Employee ID/PERNR 00553530

Name Kiranmai Chundi Branch / Office Vedayapalem

Request No MDO0000601899

Cost Center VEDAYAPALEM

Bank Account No. 31583744988 Designation Asst. (Banking)

Cadre Clerical Mobile No 9701256277

Date of Joining 15.12.2010 Intercom No.

Request Date 26.06.2013

Department (fill manually, if required):

APPROVER DETAILS

1. Patlawath Bhadru 2. 3.

CLAIM DETAILS

Type of Reimbursement: HOSPITALISATION EXP.

Nature of illness: Caesarean

Treatment Taken By: KIRANMAI CHUNDI Age: 025 Relationship: SELF

Period of Treatment From : 14.06.2013 To: 17.06.2013

Name of Doctor: K SUPRAJA Qualification of Doctor: M.B.B.S.,D.G.O.,Diab.,

Name of Hospital: Sarada Maternity Hospital

Address of Hospital: Sarada Maternity Hospital,Near Amma Auction Hall, Pogathota ,Nellore

Whether Hospital Empanelled ?: No

Hospitalisation From: 14.06.2013 To: 17.06.2013 Days: 0003

Major Head-Wise Summary of Expenditure incurred

Classification of Expenses Amount (Rs.)

COST OF MEDICINE 6960.00

BED CHARGES-EXCL. DIET CHARGES 3000.00

ANESTHESIA CHARGES 2500.00

SURGEON#S CHARGES 8500.00

OPERATION CHARGES/PACKAGE FOR OPERATION/TREATMENT 2500.00

NURSING CHARGES 500.00

OTHER EXPENSES 1600.00

TOTAL EXPENSES

Total Bill Amount: Rs. 25560.00 Amount of Advance Taken if any: Rs. 0.00

Total Amount Claimed: Rs. 25560.00

Certificate:* I certify that the expenses as detailed above were actually incurred by me.

* It is further certified that I have not received nor am entitled to any reimbursement on contribution towards such expenses under a personal

accident polity or under my claim in respect of an accident or from any other source.

I Further certify that:* The expenses as detailed above were actually incurred by me for family members wholly dependent on me.

* I further certify that my parent/s is/are wholly dependent on me and ordinarily residing with me. Further my other brothers/sisters if working in the

Bank/any other organization, they have not claimed/are not claiming reimbursement of such expenses.

* My parents are not having the monthly income exceeding the limits prescribed by the Bank.

* The family member for which the reimbursement has been claimed does not have a monthly income exceeding the limit prescribed for the

purpose in terms of the extant instructions in this regard.

* My spouse is not employed elsewhere or if employed, he/she is not entitled for reimbursement of the Medical expenses incurred. / My employed

spouse is eligible for the medical facility to the extent of Rs.NOT WORKI during the calendar/financial year from his/her employer.

* In case of treatment taken at other than the centre of posting/approved leased accommodation, necessary approval has been obtained and

copy of approval has been attached with the claim.

* In case of claim for Implant/Other transplant, necessary administrative approval has been obtained.

* This excludes children with income over Rs. 500/- per month, male children above 24 years married children.

* In case of Dental Treatment (applicable in case of officers only) necessary prior approval from the competent authority has been obtained.

Employee ID/PERNR : 00553530 Request No : MDO0000601899 Name: Kiranmai ChundiPage No.1 of 3

The Bills, receipts, supporting vouchers, prescription etc, and copy of the approval/s, where required, are enclosed with printed copyof this claim.

Date:26.06.2013 Signature of Employee

( Authorised doctor's certificate to be obtained where the treatment is taken from a physician other than the Bank's Authorised Doctor in addition to his counter signature

on the respective cash memos and receipts.)

I have scrutinized the bills and have found the claims made herein by the employee to be reasonable.

Place: Date: Signature of the Bank's Authorized Doctor

Certificate from the Forwarding Authority

The bill(s) has/have been scrutinized by me in terms of the instructions laid down in this regard from time to time. The claimmay be passed for payment for Rs. 25560.00 ( twenty five thousand five hundred sixty rupees only).

Date: Head of the Dept./Branch Manager

For Office Use

Sanctioned for payment Rs.__________________(Rupees_________________________________________________

______________________________________________________only) by debit to appropriate Charges BGL account.

Of the total Sanctioned amount Rs.

Amount Taxable

Amount Non-Taxable@@@

Remarks:

Date Sanctioning Authority @@@ Amount Exempted from income Tax for Treatment of / at Specified Diseases / Hospitals u/s 17 of IT Act is ONLY required to be

mentioned here. Please do not include exemption amount of Rs 15000/- here, system will automatically give exemption for that.

MAJOR HEAD WISE DETAILS OF EXPENSES INCURRED ANNEXURE

classification of expenses Name of the Doctor/Chemist/Lab/Hospital Bill/Cash Memo No. Dated Amount (Rs.)

COST OF MEDICINE ANU MEDICALS 467 17.06.2013 451.00

COST OF MEDICINE PADMAVATHI MEDICAL & FANCY 93 17.06.2013 303.00











BED CHARGES-EXCL. DIET

CHARGES

SARADA MATERNITY HOSPITAL 328 17.06.2013 3000.00

ANESTHESIA CHARGES SARADA MATERNITY HOSPITAL 328 17.06.2013 2500.00

SURGEON#S CHARGES SARADA MATERNITY HOSPITAL 328 17.06.2013 8500.00

OPERATION CHARGES/PACKAGE

FOR OPERATION/TREATMENT

SARADA MATERNITY HOSPITAL 328 17.06.2013 2500.00

NURSING CHARGES SARADA MATERNITY HOSPITAL 328 17.06.2013 500.00

OTHER EXPENSES SIRISHA SCAN & X-RAY CENTRE 64 14.06.2013 500.00

Employee ID/PERNR : 00553530 Request No : MDO0000601899 Name: Kiranmai Chundi

Page No.2 of 3

OTHER EXPENSES V.N. DIAGNOSTICS & X-RAY 119 15.06.2013 500.00

OTHER EXPENSES SARADA MATERNITY HOSPITAL 328 17.06.2013 600.00

Total 25560.00

Employee ID/PERNR : 00553530 Request No : MDO0000601899 Name: Kiranmai Chundi

Page No.3 of 3

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