medical reimbursement claim for outdoor treatment

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Medical Reimbursement Claim for Outdoor treatment for the month of November’13 of Sri Ashutosh Sarker, Sr. OA !"# retired on 3$%11%$& !A%N# 'ia(nostics% ests) Sl. No. *oucher No. 'ate Amount 1 R+ -1 $/%11%13 13$.$$ R+ &11-3 11%11%13 $$.$$ 3 R+ &-0-/ 1&%11%13 0$.$$ R+ &-0-- 1&%11%13 11$$.$$ 0 R+3$ 1- 1&%11%13 $$$.$$ 2O%13% $31/ %11%13 $.$$ / $/ O2 13 1 1 %11%13 $$.$$ otal 1$,0$$.$$ Medicines% 4n5ections) Sl. No. *oucher No. 'ate Amount - - & %11%13 1$$.$$ & CA 0 3- -%11%13 1//.0$ otal //.0$ "rand otal 1$,///.0$ !Rs. en housand Seven +undred and Sevent6 Seven and 7ift6 8aisa onl6 # !Si(nature of the 9m:lo6ee# Ashutosh Sarker, 9;. Sr. OA !"# Retired on 3$%11%$& !A%N# <al6ani Cash Collection O%o the Area Mana(er !2<8# Mob. No. $& 33$$- -&

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Medical Reimbursement Claim for Outdoor treatment for the month of November13 of Sri Ashutosh Sarker, Sr. TOA (G) retired on 30/11/09 (A/N)

Diagnostics/ Tests:

Sl. No.

Voucher No.

Date

Amount

1

RH281226

07/11/13

130.00

2

RH291183

11/11/13

600.00

3

RH298587

19/11/13

250.00

4

RH298588

19/11/13

1100.00

5

RH302186

19/11/13

6000.00

6

BO/13/403174

22/11/13

220.00

7

07-OB-13-12621

22/11/13

2200.00

Total

10,500.00

Medicines/ Injections:

Sl. No.

Voucher No.

Date

Amount

8

826492

26/11/13

100.00

9

CA-5438

28/11/13

177.50

Total

277.50

Grand Total 10,777.50

(Rs. Ten Thousand Seven Hundred and Seventy Seven and Fifty Paisa only )

(Signature of the Employee)

Ashutosh Sarker, Ex. Sr. TOA (G)Retired on 30/11/09 (A/N)

Kalyani Cash Collection

O/o the Area Manager (BKP)

Mob. No. 09433008489

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