Department of Medical Health and Family Welfare

Government of Uttar Pradesh

Online Application Form for Registration of Medical Reimbursement

To, Application Number : MER0012537

The Chief Medical Officer,
Distt : Agra
Uttar Pradesh
Sir,
Kindly Register my request for issuance of Medical Reimbursement which are given as
below:

1 Treatment Type:

Treatment Category For OPD Treatment

2 Employee's Detail:

Full Name J P SHARMA Father Name LATE SOHAN LAL

SHARMA

Designation SUPERINTENDENT Aadhaar No. 461192518671

ENGINEER

Date Of Birth 14/07/1940 Gender Male

Mobile No 9634646730

3 PPO detail:

Retired from Yes PPO No 19163

Employeement

4 Address of Your Treasury :

Office Name EXECUTIVE ENGINEER Office Incharge Name EXECUTIVE ENGINEER

LOWER KHAND AGRA
CANAL
 Address EXECUTIVE ENGINEER State Uttar Pradesh
LOWER KHAND AGRA
CANAL

District Agra Pincode 282005

5 Permanent Address :

Address KOTI NO 30 NORTH State Uttar Pradesh

IEDH GHAH COLONY

District Agra Pincode 282010

6 Patient`s Details:

Requesting Medical Self Hospital Type Pvt

Reimbursement for

Patient Name J P SHARMA Age 79

Gender Male Disease Name old heart injury

Place where Disease AGRA Hospital Name GLOBAL RAINBOW

Identified HEALTH CARE

Doctor Name DR R C MISHRA Treatment Period From 27/01/2019

Treatment Period To 04/02/2019 Patient Aadhaar no 461192518671

Relations with Employee Self

7 Details of expenditure:

S.No. Bill Type (/online/MER/BindChildList?sort=BillName&sortdir=ASC) Bill No. (/online/MER/Bin

1 Medicine 0117231

2 Medicine 00117282

3 Medicine 0117282
S.No. Bill Type (/online/MER/BindChildList?sort=BillName&sortdir=ASC) Bill No. (/online/MER/Bin

4 Surgical Items 0117288

5 Medicine 561824858

6 Investigation 34756

7 Medicine 0117595

8 Surgical Items 0117676

9 Surgical Items 0117544

10 Surgical Items 0117723

11 Other 56130

12 Investigation 561824887

13 Investigation 0117600

14 Surgical Items 0117482

15 Surgical Items 0117749

16 Surgical Items 0117862

17 Surgical Items 0117995

18 Surgical Items 0117969

19 Surgical Items 0117969

20 Investigation 561824958

21 Investigation 561825040
S.No. Bill Type (/online/MER/BindChildList?sort=BillName&sortdir=ASC) Bill No. (/online/MER/Bin

22 Surgical Items 0118322

23 Surgical Items 0118573

24 Surgical Items 0118322

25 Surgical Items 0118434

26 Medicine 0118750

27 Investigation 0118673

28 Medicine 0118837

29 Medicine 0118938

30 Medicine 0118935

31 Investigation 0118916

32 Medicine 0119083

33 Investigation 34934

34 Investigation 561825241

35 Medicine 0119202

36 Medicine 0119139

37 Medicine 0119393

38 Medicine 0119355

39 Investigation 561825189
 S.No. Bill Type (/online/MER/BindChildList?sort=BillName&sortdir=ASC) Bill No. (/online/MER/Bin

40 Medicine 0119454

41 Investigation 561825249

42 Medicine 0119789

43 Medicine 0119813

44 Medicine 0120092

45 Investigation 561825399

46 Medicine 0120254

47 Consultation 34765

48 Consultation 027042

49 Consultation 027006

50 Consultation 027253

51 Consultation 027559

52 Hospital Bill 027699

53 Hospital Bill 10351

8 Advance Detail:

Have you already taken No

Advance
9 Bank Details of Employee:

Bank Name BANK OF BARODA Branch Name AGRA MAIN BRANCH

Account Number 00780100006142 IFSC Code BARB0AGRAXX

Date Place Signature of Person Incharge