:

$Ir{f, dqR frJTff Rfrb / BHARAT SANCHAR NIGAM LIMITED

(g]T{d \T{dF.R ?5T 5qiF.4) ./ (Gor.t. of India undertaking)

3'iilft6 rrqr fr frq +ftdi' strdqFEnil mr srf (@)

Medical reimbursement claim for indoor treatment (Annexure - D )
@ EFf ;Ifff (Name of employee)
tld;IET (Designation)
titrfr$tl iF'. (Registration No.)
tra (Sataryl {a ta-a + ft(r
SQFI (Pensi on) (0U04/20J 41 / as on
qqe mr FsrFr (place of Duty )
qlzfr +r afa (Name of patient
)
grq
$-tft fi' fttar 6Retationship *itt ".pffi
5Jr (Aee)
frq fr * qtH-q 61qrn" of illness)
gliE{ /3fFlcilfr cFI ;Itfr (Name ofDoctor/
Hospital)

ry fiI 3l-dfr (period oftreatrnenr)

AFL tF.r fal{q @etails of claim)

(3rgcnfr h mTrft il++,d 3Tfuo,rt il'd'aoo m$rdt s drft r,rTurrFr €ara otrl
(certificate issued by the medical officer in-charge
of the hospital as per proforma is to be attached)
(quror, Erfiry 3flt * qfr{il d' ,Sild;T qttXattactr prescriprion, voucher etc. in duplicate)
ih'.No. fu{{ur /Detaits qffiR iD./ Voucher No. {tft /Amount
Wrffet / Consultation
) fqla / uh 7p6*ostics/Tests
3 E,qr$qt / g*pqpa / Medicines/Injection
4 5qiDTq /Appliances
-
5 6at 6T P.b-{rgt /Room Rent
6 fS Or qJffi' I Ctrarges of nurses
7 3f,al / Others

$-eI / Totat
f z in words Rs.
(3Tqill
5.)
dqutt / Declaration
f, w.rern dtfua mrar t 16 frt Hrn 3flr frars fi 3,2fiR 3Trtrda fr nr$
fr d'6rt {rfi t 3ik frs qfr
h R(t frBtF,d e"t r.h.gl urqr t T6 qft ir{6 frt w:rqi{Fff, tllhereuydeclarethatthestatemenrsgiveninapplication
are true to the best of my knowledge and belief
and that the person for which medical expenses
on me. are incurred is fully dependent

odrqfr h awren
Sign. of employee