FORM C

MEGHALAYA STATE ELECTRICITY BOARD

MEDICAL ATTENDANCE RULES
(MEDICAL REIMBURSEMENT BILL)
Certified that Shri/Smt______________________________________Son/wife/doughter/parents of_____________________________ Employed in
the office of_______________________ shillong has been under my treatment for __________________________disease from _____________ to
___________________ hospital/my consulting room from the recovery/ prevention of serious deterioration in the condition of patient. The
medicine are stocked in the hospital for supply to the private patients and is not include reparatory preparation for which cheaper substance of
equal theorapetic value for preparation which are primarily good or disinfectants.
Invoice No Name of Medicines Batch No Price
012014 Ch, Ao++, PT.IVR, RFT, SE, LF
FP/13968/18-19 Catheter
LD/2270 Ultrovist 370/100 ml
LD/2270 Dispovan 20
LD/2270 Dispovan 10
LD/2270 Tuucmo Headwire
LC-L106979 21N-Q10 cup 10’s
LC-L106979 Levera 500 mg Tab 15’s
LC-L106979 Rloc 150 mg Tab 30’s
LC-L106979 ARK75SR Tab 10’s

Signature and designation

Of Authorised Medical Attendant