You are on page 1of 2

The Road Development Authority

Medical Scheme

To: medical Committee, Thro Head of Division

Medical leave obtained from.. to .. .


Signature
Head of Division

Year :..
To. Secretary, Committee of Medical, RDA

1. Name of Applicant (Name in Full) : _________________________________________


2. Designation : __________________ 3. Whether Permanent / Contract / Casual : ______________
4. Employment No. _________ 5. Division Code :_________
6. Place of Work (Division / Office) : ________________
7. Residential Address : _____________________________________________________________________
8. Name of Patient : ________________________________________________________________________
9. Relationship of Patient : _____________________
10. Whether reimbursed of this year earlier ? Yes / No. If yes the amount reimbursed Rs. __ __Cts.______

I hereby request the reimbursement of the sum of Rupees ________________________


(Rs.__________Cts___) being 80% of the medical expenses incurred by me for obtaining medical advice and
treatment from ___/____/_______ to ____/____/_______. All supporting bills, prescriptions, test reports
are annexed and the details filled in columns 1 3 overleaf.

Date: _________________ Signature of Applicant

To : Medical Committee

Payment of Rupees _____________________________________ and cts.______ (Rs._________ cts.________)


is recommended as per particulars shown in column 4 overleaf.

Out-door treatment Hospitalization


Rs.2,000/- Rs.10,000/- Rs.15,000/- Rs.15,000/-
This amount is reimbursed
Balance

Signature of Clerk ________________ _________________


Senior Accountant
Date: ______________ (Sec. of Medical Committee)

Note :
1. Indicate the name and the relationship of the dependents.
2. If the member was on leave during the period of sickness please mention the same.
3. If any member submits medical bill in a fraudulent manner such member will be liable for disciplinary
action.
4. Please mention the amount reimbursed during the year.

Description of Bills
Form : MS/2A
Page : 02-02
(1) (2) (3) (4) (5)
Total 80% Approval
Rs. Cts. Rs. Cts Rs. Cts
1. Hospitalization
A. Name of Hospital
B. Period Fromto
No. of bills
2. Out-door
(According to 80% Approval Reason for
treatment (Institution Date of Bill
the Serial No.) Reject
/ Doctor)
Rs. Cts. Rs. Cts. Rs. Cts

Total

Approved / Not Approved

Rs.. cts.

Members of Committee

1. 2..
3..

Date:..
Payment Made

Amount (in word) Rs..


cts. (Rs..cts.)

Cheque No.

Voucher No.

Date:.. ..
Senior Accountant

Received Rupees .. and cts. . In full


settlement of the above account.

Date: Signature of Applicant: