FORM FOR REIMBURSEMENT OF MEDICAL CHARGES

Sr. No Name and Relationship of Disease as diagnosed Name of the medicine on Amount of the Place of Reason for incurring Period of Remarks of
the Patient with the Govt. by the R.M.P. account of which the Bill Voucher Posting expenditure at a place treatment Medical Officer
University employee expenditure was incurred other than place of
duty/posting
1 2 3 4 5 6 7 8 9
Jyoti Bhuken w/o Sh. Delivery of baby Admission Fee 300.00 PAU, Ldh. 30-01-2016 to
Sarvesh Kumar, Asstt. Pathology 290.00 03-02-2016
Professor, Department of Blood Bank 200.00
Civil Engg., PAU,
Ludhiana Biochemistry:- 1830.00
Paediatric 200.00
Visiting fee ICU 900.00
Nursing care charges 300.00
M.C.H. Cardh 60.00
Nursery isolation 8700.00
Admission Fee Pvt 1500.00
Room Rent 14700.00
Operation fee Pvt 24600.00
Anaesthesia Fee Pvt 5600.00
Visiting fee 100.00
Visiting fee 200.00
Visiting fee Pvt 2800.00
Suture Charges 1350.00
Pathology 410.00
Paediatric 900.00
Gynae 600.00
Dietician consulation 150.00
CSSD 350.00
Nursing care charges 850.00
Pulse Oxymeter 300.00
Pharmacy charges 1757.00
Balance C/D 68947.00
Note: Prescriptions should include: - Certified that:
a) Number of the Registered Medical Practitioner. i) The patients, as mentioned above are wholly dependent upon
b) Name of the medicine in legible handwriting ii) me and
They havewith
reside got no
meother
at thesource
place of income.
my duty.
c) Quantity of medicine to be purchased from the market iii) The medicines purchased have been fully used.
d) Cash memos/vouchers should be duly verified and attested by the employee iv) Registered number of medical practitioner is PAU
e) concerned in medicine
Name of the token of payment having
to be given been made.
in capital letters on the reverse side of the voucher v) Treatment is completed / continuing.
f) Sanction of the competent authority to be enclosed.

Counter signature
 Signature of the employee (Head of the Section Officer)

FORM FOR REIMBURSEMENT OF MEDICAL CHARGES

Sr. No Name and Relationship of Disease as diagnosed Name of the medicine on Amount of the Place of Reason for incurring Period of Remarks of
the Patient with the Govt. by the R.M.P. account of which the Bill Voucher Posting expenditure at a place treatment Medical Officer
University employee expenditure was incurred other than place of
duty/posting
1 2 3 4 5 6 7 8 9
Balance B/D 68947.00
Jyoti Bhuken w/o Sh. Delivery of baby O.T expenses 8050
Sarvesh Kumar, Asstt. Discharge record file 50.00 30-01-2016
Professor, Department of Recovery bed charges 3,500.00 to 03-02-2016
Civil Engg., PAU,
Ludhiana Hemogram complete 300.00
PTI 230.00
PTTK 230.00
Urine routine 70.00
Grand Total (Rs.) 81377.00
Note: Prescriptions should include: - Certified that:
a) Number of the Registered Medical Practitioner. i) The patients, as mentioned above are wholly dependent upon
b) Name of the medicine in legible handwriting ii) me
Theyand havewith
reside got no
meother
at thesource
place of income.
my duty.
c) Quantity of medicine to be purchased from the market iii) The medicines purchased have been fully used.
d) Cash memos/vouchers should be duly verified and attested by the employee iv) Registered number of medical practitioner is PAU
e) concerned in medicine
Name of the token of payment having
to be given been made.
in capital letters on the reverse side of the voucher v) Treatment is completed / continuing.
f) Sanction of the competent authority to be enclosed.

Counter signature
Signature of the employee (Head of the Section Officer)
 FORM FOR REIMBURSEMENT OF MEDICAL CHARGES

Sr. No Name and Relationship of Disease as diagnosed Name of the medicine on Amount of the Place of Reason for incurring Period of Remarks of
the Patient with the Govt. by the R.M.P. account of which the Bill Voucher Posting expenditure at a place treatment Medical Officer
University employee expenditure was incurred other than place of
duty/posting
1 2 3 4 5 6 7 8 9
Balance B/D 81377.00
Jyoti Bhuken w/o Sh. Delivery of baby Venflon pro canula 20g 62.40
Sarvesh Kumar, Asstt. Vein-guard 19.80 30-01-2016
Professor, Department of Infusion set rms 23.00 to 03-02-2016
Civil Engg., PAU, Vein o line 33.00
Ludhiana
Digital thermometer 94.40
Plastic tray 58.65
Gillete shaving razor 18.00
Emerald syringe with needle 23.00
Emerald syringe 5ml 10.50
Normal 18G needle 7.65
Keftaglan 1gm Inj 91.71
Normal Saline 9.50
Romo Jet 1ml 3.24
Rantac 50mg inj 3.04
DNS 500 ML glass 31.97
Normal Saline 19.00
Keftaglan 1gm Inj 183.42
Genticyn 80GM 9.07
Infusion set rms 23.00
Emerald Syrindewith needle 17.25
Huggies small 99.00
Keftaglan 1gm Inj 183.42
Normal Saline 18.70
Genticyn 80GM 4.54
Dynatroy AQ Inj 49.92
Balance C/D 82474.18
Note: Prescriptions should include: - Certified that:
a) Number of the Registered Medical Practitioner. i) The patients, as mentioned above are wholly dependent upon
b) Name of the medicine in legible handwriting ii) me and
They havewith
reside got no
meother
at thesource
place of income.
my duty.
c) Quantity of medicine to be purchased from the market iii) The medicines purchased have been fully used.
d) Cash memos/vouchers should be duly verified and attested by the employee iv) Registered number of medical practitioner is PAU
e) concerned in medicine
Name of the token of payment having
to be given been made.
in capital letters on the reverse side of the voucher v) Treatment is completed / continuing.
 f) Sanction of the competent authority to be enclosed.
Counter signature
Signature of the employee (Head of the Section Officer)

FORM FOR REIMBURSEMENT OF MEDICAL CHARGES

Sr. No Name and Relationship of Disease as diagnosed Name of the medicine on Amount of the Place of Reason for incurring Period of Remarks of
the Patient with the Govt. by the R.M.P. account of which the Bill Voucher Posting expenditure at a place treatment Medical Officer
University employee expenditure was incurred other than place of
duty/posting
1 2 3 4 5 6 7 8 9
Balance B/D 82474.18
Jyoti Bhuken w/o Sh. Delivery of baby Rantac 50MG inj 9.13
Sarvesh Kumar, Asstt. Kabimol 100ml glass 652.61 30-01-2016
Professor, Department of NU patch 144.90 to 03-02-2016
Civil Engg., PAU, Ringer lactate 500ml 52.16
Ludhiana
Emerald 5ml syringe 14.00
Omnivan 10ml duo 14.58
Keftaglan 1gm inj 91.71
normal saline 9.50
Kabimol 100ml glass 489.46
NU patch 144.90
bed bath wipes 142.50
DNS 500ml glass 95.90
Ringer lactate 500ml 104.31
normal 18g needle 19.13
Omnivan 10ml duo 24.30
Huggies small (5pc) 99.00
Huggies small (5pc) 49.50
Gentle baby wipes 24 135.00
Gentle baby wipes 24 67.50
Livogen-Z 152MG 148.80
Sandocal 500MG 318.17
Bevon Drops 15ml 79.23
Augmentin tab 233.76
Rantac 150 mg tab 3.25
Lyser-d tab 54.82
Balance C/D 85672.30
Note: Prescriptions should include: - Certified that:
a) Number of the Registered Medical Practitioner. i) The patients, as mentioned above are wholly dependent upon
b) Name of the medicine in legible handwriting ii) me
Theyand havewith
reside got no
meother
at thesource
place of income.
my duty.
c) Quantity of medicine to be purchased from the market iii) The medicines purchased have been fully used.
d) Cash memos/vouchers should be duly verified and attested by the employee iv) Registered number of medical practitioner is PAU
concerned in token of payment having been made.
 e) Name of the medicine to be given in capital letters on the reverse side of the voucher v) Treatment is completed / continuing.
f) Sanction of the competent authority to be enclosed.

Counter signature
Signature of the employee (Head of the Section Officer)
FORM FOR REIMBURSEMENT OF MEDICAL CHARGES

Sr. No Name and Relationship of Disease as diagnosed Name of the medicine on Amount of the Place of Reason for incurring Period of Remarks of
the Patient with the Govt. by the R.M.P. account of which the Bill Voucher Posting expenditure at a place treatment Medical Officer
University employee expenditure was incurred other than place of
duty/posting
1 2 3 4 5 6 7 8 9
Balance B/D 85672.30
Jyoti Bhuken w/o Sh. Delivery of baby Livogen-z 152mg tab 14.88
Sarvesh Kumar, Asstt. Sandocal 500 mg tab 31.82 30-01-2016
Professor, Department of Becosule z cap 11.68 to 03-02-2016
Civil Engg., PAU, Calshine p Drops 300.00
Ludhiana
protinex elaichi 440.00
Soframycin cream 28.16
Ringer lactate 500ml 104.31
normal 18g needle 19.13
omnivan 10ml 24.30
Huggies small 99.00
Gentle baby wipes 67.50
Coconut oil 52.20
digital thermometer 94.40
normal 26g needle 15.75
Avagard Chg handrub 108.54
Gillete shaving razor 18.00
Avagard Chg handrub 108.54
Genticyn 80mg 4.54
Phenergen 25mg Inj 12.46
Romo jet 50ml 24.00
Connecta 100cm 122.50
Connecta 10cm 92.40
Polyyvol burette set 88.50
Normal saline 9.35
Dextrose 10% 500mlo 25.90
Balance C/D 87590.16
Note: Prescriptions should include: - Certified that:
a) Number of the Registered Medical Practitioner. i) The patients, as mentioned above are wholly dependent upon
b) Name of the medicine in legible handwriting ii) me and
They havewith
reside got no
meother
at thesource
place of income.
my duty.
c) Quantity of medicine to be purchased from the market iii) The medicines purchased have been fully used.
 d) Cash memos/vouchers should be duly verified and attested by the employee iv) Registered number of medical practitioner is PAU
e) concerned in medicine
Name of the token of payment having
to be given been made.
in capital letters on the reverse side of the voucher v) Treatment is completed / continuing.
f) Sanction of the competent authority to be enclosed.

Counter signature
Signature of the employee (Head of the Section Officer)
FORM FOR REIMBURSEMENT OF MEDICAL CHARGES

Sr. No Name and Relationship of Disease as diagnosed Name of the medicine on Amount of the Place of Reason for incurring Period of Remarks of
the Patient with the Govt. by the R.M.P. account of which the Bill Voucher Posting expenditure at a place treatment Medical Officer
University employee expenditure was incurred other than place of
duty/posting
1 2 3 4 5 6 7 8 9
Balance B/D 87590.16
Jyoti Bhuken w/o Sh. Delivery of baby Gluci 500mg 32.40
Sarvesh Kumar, Asstt. Omnivan 10ml 9.72 30-01-2016
Professor, Department of Romo jet 1ml 6.48 to 03-02-2016
Civil Engg., PAU, Needle 23 g 7.35
Ludhiana
Neoflon 24G peadiatric 72.00
Tegaderm 79.47
Venflon pro canula 62.40
Vein-guard 19.80
Infusion set rms 23.00
Vein o line 10cm 33.00
Digital thermometer 94.40
Plastic tray 58.65
Gillete shaving razor 18.00
Emerald syringewith needle 23.00
Emerald syringewith needle 10.50
Normal 18G needle 7.65
Keftaglan 1gm inj 91.71
Gluci 500mg 32.40
Huggies small 99.00
Gentle baby wipes 67.50
Nazone drops 36.00
Rantac 150mg tab 6.50
lyser-d tab 137.05
Neoflon 24G peadiatric 144.00
Tegaderm code 79.47
Balance C/D 88841.61
Note: Prescriptions should include: - Certified that:
a) Number of the Registered Medical Practitioner. i) The patients, as mentioned above are wholly dependent upon
b) Name of the medicine in legible handwriting ii) me and
They havewith
reside got no
meother
at thesource
place of income.
my duty.
 c) Quantity of medicine to be purchased from the market iii) The medicines purchased have been fully used.
d) Cash memos/vouchers should be duly verified and attested by the employee iv) Registered number of medical practitioner is PAU
e) concerned in medicine
Name of the token of payment having
to be given been made.
in capital letters on the reverse side of the voucher v) Treatment is completed / continuing.
f) Sanction of the competent authority to be enclosed.

Counter signature
Signature of the employee (Head of the Section Officer)

FORM FOR REIMBURSEMENT OF MEDICAL CHARGES

Sr. No Name and Relationship of Disease as diagnosed Name of the medicine on Amount of the Place of Reason for incurring Period of Remarks of
the Patient with the Govt. by the R.M.P. account of which the Bill Voucher Posting expenditure at a place treatment Medical Officer
University employee expenditure was incurred other than place of
duty/posting
1 2 3 4 5 6 7 8 9
Balance B/D 88841.61
Jyoti Bhuken w/o Sh. Delivery of baby Romo jet 1ml 6.48
Sarvesh Kumar, Asstt. Micropore 1x10d 49.30 30-01-2016
Professor, Department of Bed pan with cover sleek 114.29 to 03-02-2016
Civil Engg., PAU, Primapore 86.25
Ludhiana
Keftaglan 1gm 183.42
Normal saline 19.00
Genticyn 80mg 8.77
NU Patch 200 144.90
Normal 18G needle 3.83
Huggies small 247.50
Gentle Baby wipes 270.00
Keftaglan 1gm inj 91.71
Normal saline 9.50
Genticyn 80mg 4.38
Genticyn 80mg 4.54
Primapore 25cm 86.25
Emerald syringewith needle 5.75
Emerald syringewith needle 3.50
Livogen captab 34.63
Snadocal 500mg tab 53.03
Supradyn tab 12.83
Protinex original 250 gm 269.10
Balance C/D 90550.57
Note: Prescriptions should include: - Certified that:
a) Number of the Registered Medical Practitioner. i) The patients, as mentioned above are wholly dependent upon
b) Name of the medicine in legible handwriting ii) me and
They havewith
reside got no
meother
at thesource
place of income.
my duty.
c) Quantity of medicine to be purchased from the market iii) The medicines purchased have been fully used.
d) Cash memos/vouchers should be duly verified and attested by the employee iv) Registered number of medical practitioner is PAU
e) concerned in medicine
Name of the token of payment having
to be given been made.
in capital letters on the reverse side of the voucher v) Treatment is completed / continuing.
f) Sanction of the competent authority to be enclosed.

Counter signature
Signature of the employee (Head of the Section Officer)