Medical Reimbursement Proposal

1. Employee Type

In-Service Pensioner

2. Employee Details

Employee Name Designation Basic Pay Scale of Pay Name of the School/Office Name of Mandal Name of District Employee Treasury ID Contact Phone No.

3. Residential Address

Complete Residential Address including PIN Code

4. Patient & Treatment Details

Patient Name Relationship with Employee Patient Age Hospital Type Name of Hospital Hospital Recognition Upto Disease / Diagnosis Hospital Admission Date Date of Discharge Date of Submission Spell Availed Amount Claimed

5. DDO Details

DDO Designation DDO Office Name Mandal District Proceedings No DDO Code

6. Pensioner Details

Pension PPO No. Pension Pay Pension Bank Account No. Bank Name Branch Name / Place Mandal / Town / City Bank IFSC Code