Medical Reimbursement Form PDF

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Medical Reimbursement Form PDF Download in for free using the direct download link given at the bottom of this article.

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.

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

Medical Reimbursement Form PDF - 2nd Page
Page No. 2 of Medical Reimbursement Form PDF

Details to be Mentioned in Medical Reimbursement Form

  • 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

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.

Also, Check –

Medical Reimbursement Form for Pensioners

Medical Reimbursement Form for Service Beneficiary

Medical Reimbursement Form PDF Download Link

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