Medical Reimbursement Form PDF

This is a Medical Reimbursement application form for claiming medical expenses incurred in cash for the treatment of your family. You can get reimbursement of these expenses by submitting the original bills to your employer. They will refund the amount spent, as long as it falls within the overall limit of Rs 15,000, without any tax deduction.

Medical reimbursement is a helpful facility where employers pay back uninsured general medicine or accident expenses incurred by employees or their dependents. You can easily download the Medical Reimbursement Form in PDF format from the link at the bottom of this page, making the process straightforward and efficient.

Details to Include in the Medical Reimbursement Form

Medical Reimbursement Form – Essential Details

• Name and Designation of the Government Employee
• Office in which Employed
• Place of Duty
• Permanent Address
• Name of Patient and their relation with the Government servant
• Details of the Amount Claimed
• Hospital Treatment
• And any other relevant details

Eligibility Criteria for Medical Reimbursement

• Employees must have personally spent the amount on medical treatment.
• The expenses should be for their own or their family members’ treatment.
• The amount claimed must be reimbursed by the employer.
• The total amount reimbursed by the employer cannot exceed INR 15,000 within the financial year.

Documents Required for Medical Reimbursement Form

• Completed Medical Reimbursement Application Form
• Hospital Discharge Summary (Original)
• Case receipts from hospitals or chemists
• Copy of Health Card
• If the claim is due to an accident, then FIR or medico-legal certificate (MLC)
• And any other necessary details.

Medical Reimbursement is a convenient arrangement where employers return a portion of health expenses incurred by their employees. According to the Income Tax Act, tax exemption of up to INR 15,000 applies to medical reimbursements provided by employers.

This certification indicates that the case did not require hospitalization. However, it is of prolonged nature, needing medical attendance at the outpatient department for more than 10 days.

You can download the Medical Reimbursement Form in PDF format from the link below for easy processing of your claims. 📄