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(Also available on SCyBernet > India > Human Resources > Useful Forms> Payroll Forms)



 
  



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Name of Patient

Relationship with Employee

Name of Employee

Bank ID

Grade


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I have incurred on account of hospitalization due to disease/illness/accident, expenses as per the

details given. In support of the claim, I enclose the following documents:

1. Bill receipt and 1#!


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from the Hospital
2. Schedule of Treatment / Test certified by the Hospital
3. Cash memos, bills and receipts from the hospital / chemists / diagnostic centre, supported with
prescriptions
4. Medical costs connected with Post-Hospitalization Domiciliary Care
5. Tax Exemption Certificate from the Hospital (If applicable)



 
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Nature of Disease / illness contracted or injury
sustained
Name and Address of the Hospital/Nursing Home /
Clinic
Date of Admission
Date of Discharge
Period of Post-Hospitalization Domiciliary Care
Name and Address of attending Medical Practitioner
for Domiciliary Care
Total Bill Amount paid to the Hospital

Please reimburse the permissible amount as per the rules.

Date:

Place Signature of Claimant Signature of Line Manager

(For claims above INR 50,000)


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Total amount payable under the claim Rs._____________ Taxable Rs.___________
Net amount payable Rs._____________ Non Taxable Rs. ______
Prepared by: Checked by: Approved by:
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1. Cancer
2. Tuberculosis
3. Acquired immunity deficiency syndrome
4. Disease or ailment of the heart, blood, lymph glands, bone marrow, respiratory system, central
nervous system, urinary system, liver, gall bladder, digestive system, endocrine glands or the skin,
requiring surgical operation
5. Ailment or disease of the eye, ear, nose or throat, requiring surgical operation
6. Fracture in any part of the skeletal system or dislocation of vertebrae requiring surgical operation or
orthopedic treatment
7. Gynecological or obstetric ailment or disease requiring surgical operation, caesarean operation or
laparoscopic intervention
8. Ailment or disease of the organs mentioned in # 4, requiring medical treatment in a hospital for at
least three continuous days
9. Gynecological or obstetric ailment or disease requiring medical treatment in a hospital for at least
three continuous days
10. Burn injuries requiring medical treatment in a hospital for at least three continuous days
11. Mental disorder - neurotic or psychotic - requiring medical treatment in a hospital for at least three
continuous days
12. Drug addiction requiring medical treatment in a hospital for at least seven continuous days
13. Anaphylactic shocks including insulin shocks, drug reactions and other allergic manifestations
requiring medical treatment in a hospital for at least three continuous days