Medical Expense Reimbursement Request

The document is a request for reimbursement of medical expenses by an employee for spectacles purchased for their spouse. It provides details of the bill amount and requests forwarding to the medical coordinator for approval.

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shankar anand shindhe

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Medical Expense Reimbursement Request

Uploaded by

shankar anand shindhe

We take content rights seriously. If you suspect this is your content, claim it here.

Available Formats

Download as PDF, TXT or read online on Scribd

FOR OFFICERS

Reimbursement of Medical Expenses for Self and Family for the Financial year : 2021

You are requested to Please Attach a Copy of Prescription along with Original Bills / Cash Memos

Employee Name:S Shankar Anand To: Medical Co-ordinator : Kutty C Sankaran (23063352)

Token Number: 23163937 Dept. Name: Engines FD, Chennai

Contact No: 9840222527 PA: TRK PTD ADV TEC & MRV CMN SRV Date : 31-Jan-21

Claim No: 2316393700032 Grade: L7-Operational Cost Center :FP1124

Kindly arrange to reimburse the Medical Expenses incurred by me as per details given below:

Reimbursement towards Spectacle Expenses

Sr. No Bill. No Date Name of the Chemist/Doctor/Clinic Name: Self/Spouse/Child Amount(Rs.)

1 786 24/01/21 LensKart Spouse Naga Usha S 839.00

Amount Sanctioned: 839.00 * Amount Applied: 839.00

* Subject to Approval

Employee Signature

Remarks of the
Medical Officer:
Employee token No. 23163937

Please forward the bills/prescriptions to the Medical Co-ordinator along with this form.

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Medical Expense Reimbursement Request

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Medical Expense Reimbursement Request

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FOR OFFICERS

Token Number: 23163937 Dept. Name: Engines FD, Chennai

Claim No: 2316393700032 Grade: L7-Operational Cost Center :FP1124

Reimbursement towards Spectacle Expenses

Sr. No Bill. No Date Name of the Chemist/Doctor/Clinic Name: Self/Spouse/Child Amount(Rs.)

1 786 24/01/21 LensKart Spouse Naga Usha S 839.00

Amount Sanctioned: 839.00 * Amount Applied: 839.00

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