Medical Reimbursement Form

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Medical Reimbursement Form

This is a Medical Reimbursement application form for a claim of medical expenses incurred by the insured person in cash for the treatment of the family. One can claim reimbursement of medical expenses by submitting the original bills to the employer. The employer would accordingly reimburse such expenses incurred subject to the overall limit of Rs 15,000 without tax deduction.

Medical reimbursement is a facility where an employer reimburses uninsured general medicine or accident expenses incurred by the employee or his dependents. The medical Reimbursement form PDF can be downloaded from the link given at the bottom of this page.

Medical Reimbursement Form 2024– Details to be Mentioned

  • Name and Designation of Government Employee
  • Office in which Employed
  • Place of Duty
  • Permanent Address
  • Name of Patient and his/her relation with Government servant
  • Details of amount Claimed
  • Hospital Treatment
  • And any other details

Medical Reimbursement Eligibility

  • Employees should have spent the amount on medical treatment.
  • The amount should have been spent on his own or his family members’ treatment.
  • Such an amount should be reimbursed by the employer.
  • Amount reimbursed by the employer does not exceed INR 15,000 in the financial year.

Medical Reimbursement Form – Document Required

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

Medical Reimbursement is an arrangement under which employers reimburse the portion of the health expenses incurred by the employee. The Income Tax Act allows tax exemption of up to INR 15,000 on medical reimbursements paid by the employer.

It is certified that the case did not require hospitalization but is one of prolonged nature, requiring medicine attendance at the our-patient department spreading over a period of more than 10 days.

You can download the Medical Reimbursement Form in PDF format online from the link given below.

2nd Page of Medical Reimbursement Form PDF
Medical Reimbursement Form

Medical Reimbursement Form PDF Free Download

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