Medical Reimbursement Form

H.P.T.R. 6 MEDICAL CHARGES REIMBURSEMENT FORM 1. Name and Designation : ______________________________________________ 2. Treasury Employee Code : ______________________________________________ 3. Office in which Employed : ______________________________________________ 4. Basic Pay : Rs.______________________+ Allowance 5. Name of Patient & Relation with the Claimant : ___________________________ (Extractive summary — verify with official source.)