Application form for Payment Of Medical Reimbursement


Note: 1. You may fill this form by entering the applicant’s eHRMS Code and clicking on ‘Search’ to fetch the details available on the Manav Sampada Portal. Any mandatory information not fetched automatically must be filled in by the applicant. Alternatively, the form may be completed manually.
2. Alternatively, you may obtain a forwarding letter signed by the Head of your Department (Reporting Officer) before submitting the online application.
3. If you have a single bill that includes expenses from different categories, the same bill must be uploaded separately against each applicable category of expense.

Page:1 (Employee, Employer, Patient, Treating hospital and Treatment details)

Employee Detail

       

Employer/Posting Details

Patient's Details

Note :- If the age is less than 1 year, mention it as 1 year.
   

Treating Hospital Details

   
   

Details of Treated Disease


























































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