UNIVERSITY OF PESHAWAR MEDICAL REIMBURSEMENT FORMT oThe Treasurer, University of Peshawar.Subject: Medical ReimbursementI have sent a sum of Rs.!Ruees" on the treatment of my Self#wife#Son#$au%hter#&ather#Mother as er followin% brea'down:(S.No. Cash Memo No. Dated Amout!"#$)ecessary *ash Memos alon%with resective rescrition chits, ori%inal $ischar%e *ardand Photo coy of the comlete +dmission Treatment *hart and )ursin% *hart inta'e outut record oftheatient duly attested by the Re%istrar of the ward#RM, of the -osital +reattached. I solemnlydeclarethat theclaimis correct andshall beheldresonsiblefordiscilinary action on account of miss(statement or over claimin%. It is re.uested that re(imbursement aser rulesmay'indlybemadetome. $etail of Medical Treatment e/enditureismentionedintheattached )on +vailability *ertificate.S%&atu'e A(()%*at Name Mo+%)e NoRe*ommedat%o o, the Head o, De(a'tmet*ertifiedthat thealicant isare%ularemloyeeof theUniversityof Peshawarandwor'in% as. undermysuervision.Theinformationasfurnishedabovebyhim#herare correct. The bill!s" are forwarded for reimbursement.Head o, De(a'tmet-Ist%tut%osNo DatedNote 0. If thebill amount e/ceeds from Rs.1222#( then two sets of bill !,ri%inal 3 Photocoy"sets of bill must be submitted4. $eendence certificates in case of father#mother may be attached and hotocoy of )I*of alicant andatient must be attached!deendencecertificateformavailablein+ccounts Section" FOR USE OF ACCOUNTSSECTIONRe&%ste' NoPa&e No S.NoThe bill!s" have been chec'ed. + sum of Rsis ermissible under the rules.Med%*a) Asstt Su(dt. A**outs De(ut/ T'easu'e FOR USE OF AUDIT SECTIONRe*e%0ed Che1ue No.Dated Rs. Pa/ee2s S%&atu'e NONAVAILABILITY CERTIFICATEIt iscertifiedthat themedicineswhosecost isbein%claimedfor re(imbursewererescribed for the treatment of the under mentioned atient. $ue to non(availabilityofthe medicine or their substitute in the store of this -osital, urchaseof these medicines from the mar'et was necessary.)ame of Patient:$isease: &ather#Mother#5ife#Son#$au%hter of: $eendent on : $esi%nation$ett:#*olle%e#Section Deta%)s o, (u'*hased med%*%es *ash memos a'e as ude' .3S.No. Cash Memo No. Dated. Amout 4Rs.51.2.3.4.5.6.7.8.9.10.11.12.13.14.15.Total Rs. !Ruees "Re&%st'a'-Med%*a) O,,%*e'. Wa'd No.Hos(%ta). Stam(. Coute's%&edRes%det Med%*a) O,,%*e'Hos(%ta) Stam(DEPENDENTCERTIFICATEThis i st ocert i fyt hat Mr# Msi swor'i n%as 666666666666666666i n t hi s offi ce. -e # She i s a ermanent eml oyee of t heUni versi t yof Peshawar. -is # her &ather # Mother #-usband #5ife # Son# $au%hter namel y666666666666666666666i s l i vi n%wi t hhi m# herand is fully deendent on hi m# heri ncl udi n%medi cal t r eat ment . -e# Shehas noot her ersonfor hi s# her medi calcare.&urther this atient is neither emloyed or not 7ovt. servant #retired emloyeeand not he #she is %ettin% any ension #Medical covera%e from anywhere.6666666666666666666666666666666666666666666666666666666666666664S%&atu'e o, theHead o, De(a'tmet-Se*t%o-Co))e&e ad O,,%*e Stam(.5