Professional Documents
Culture Documents
Medical Scheme
Year :..
To. Secretary, Committee of Medical, RDA
To : 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
Rs.. cts.
Members of Committee
1. 2..
3..
Date:..
Payment Made
Cheque No.
Voucher No.
Date:.. ..
Senior Accountant