Human Resource Division

REQUEST FOR APPROVAL OF HOSPITALIZATION BILL

Date: _________________

Particulars Employee Information

Name: Employee #
Basic Salary: Date of Joining:
Entitlement for this Year: Functional Title:
Hospitalization availed: Rs. Grade: Driver
Balance: Office/Division/Branch:
Nature of Disease / Surgery:
Amount of Bill: Rs.

Hospitalization Information
Patient’s Name:
Relationship with employee: Father
In case of Maternity, Number of cases availed from the Bank:
Prior approval of Head Office:
(In case “Yes” enclose copy of approval) YES
Name of Hospital:
Hospitalization period: From To for 0 Days.

Original Hospitalization Admission/discharge certificate and medical bills/receipts are enclosed.

Verified by: ________________________________ ___________________________

(Name, Designation & Signature) Signature of Applicant

Recommendations for Hospital Facility

By Division/Branch By Group Head/Regional/Area Office

Signature:_____________________________ Signature:_____________________________

Name & Designation:____________________ Name & Designation:____________________

Decision of Competent Authority

Reference No: HO/HRD/______________ Date:_______________
An amount of Rs. ________________ (Rupees ____________________________________________________
______________________________ ) is Sanctioned / Rejected, under Hospitalization Policy. The amount
may be reimbursed to the above named employee, debiting proper head of account.

____________________ ____________________
SVP-HRD Country Head-HRD