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Detztits of claim

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(Tick relevant box) i 't Treatrnent fuonr itMP (is pcr para 2,1-0) I Treaiment from p&T Dispensary (as per Fnrn Z,l.?) .i (Attach prescription, vouchcrs, etc. in eluplicate)
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TI F::t:dge and belief and that ihe p"rron for which medical expcnses are incun.e<J rs wnolly dependent on me.
(Signaturo of Employcc)

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attached with the clairn,'fonn

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Mark('{ ) if Yes

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Whethet Medical leimb ursement .claims Fqrm (Anuexure-C) dply hUaa in all columns including mfvfs Xq, is qttachea i'u drfiplicatewith the claim? Whether claim is subinitted iu foUon{ng order:.: 1. Origioal copy of Annex-C,2. Prescription slip,1. Receipt of.consultation fee, 4. Medicines.bills;5. Receipt of Lab Tests,6, Receiirt of Appliinces (if any), T.Receipt of Physiottrerapy charaes,.8. Receipt of Yoga etc,9; Receipt of any other charges, 10, Duplicate copy oJ Annexure-C? Atrl the documents should be given Srj No. Whether,prescription (Original/ Photo copy) & Cash,memos for nredicines purchased, teSts, consultation fee &'other documents r" qre attached in orisinal? . Whether mgdiciues aud tests match with those prescribed on thc prescription slib? Whethpr theDoctor for long-term diseases like Hyperteasion(tsf)t thyqoid br'diabetes,etc. has mentioned on the prescription that the treatrnent is of lohg teym nature aud mentioued the period for which.the medicin&has to be taktin? ' \Yhether the details of list claims submiffed is giveil iu case of long-term treatmeat.on Claim Form (Annerure0? . \ilhbther the cobtactNo,, BdukA/cNo., Name of Bank& brauch addrbss, IFSC code of the bank provided., ln case of re-fired dmployee? trf No, f:coplbf bladkchegue duly:sang'o1led'rbay be submitted alons with the claim (one tirne exercise) Whgther Revalidation of.BSNLMRS facitity undeitaking & copy of Pi\N card sribmitted in the month of Aprit for the year for whicli:claim relateto? (To bi submitted bvthe r:titired emplqygesl \ilhether all docurnents ettached with the claim are self-atte$ted? Any ot\er documeut attaOrea wlth t
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rte . This checklist must be ittacheA wlth'each reinibuisernent claim.

(Nu-q &'Signatwc of EmPloYee) PhoueNo. l

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