Are you looking for a way to simplify your business operations? Do complex forms and documentation fill up too much of your time and resources? If you answered yes to either of these questions, the Hptr 6 form is here to help! This easy-to-use electronic filing system allows businesses across Australia to securely manage their documents online without wasting valuable time or resources. Keep reading this blog post to learn more about how the Hptr 6 form can increase efficiency in your organization.
| Question | Answer |
|---|---|
| Form Name | Hptr 6 Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | hptr 6, hptr 6 medical reimbursement form, hptr 6 form, medical reimbursement form hp |
H.P.T.R.6
MEDICAL CHARGES REIMBURSEMENT FORM
1. |
Name and Designation |
:……………………………………………………. |
2. |
Office in which Employed |
:……………………………………………………. |
3. |
Basic Pay |
:……………………………………………………. |
4.Name of Patient & relation with the Claimant
5. |
Period of Illness |
:………………………………………………….. |
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6. |
PARTICULARS OF TREATMENT: |
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Item Names |
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Charges |
Details of |
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(i) Medicines (Name) |
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(ii) Laboratory Tests/Ambulance/Consultancy/Indoor Room/Others (Specify)
6. Total Claim |
Rs……………… |
7. Less- Advance Drawn vide T/V |
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No…………………. Dt……………..Rs…………………… |
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8. Net Amount Payable |
Rs…………………… |
I hereby declare that the statements in this application are true to the best of my knowledge and belief and that the person for whom medical expenses were incurred is wholly dependent on me.
Date ………………… |
Signature of the DDO |
VARIFICATION CERTIFICATE
I, Dr …………………………. Hereby certify that ……………………………………………
Suffering from ………………………………….. and is /was under my treatment from ……………
To ……………………. And that the above mentioned medicines/ test were prescribed by me in this
connection.
This claim is verified for Rs………………………
Date…………………….. |
(Signature of Medical Officer) |
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Designation & Seal |
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Passed for Rs…………………(Rupees……………………………………………….)
And included in Bill No……………………………….Dated………………………….
(Signature of Controlling Officer) |
(Signature of the DDO) |
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INSTRUCTIONS
1.List all the medicines, tests etc. individually.
2.Attach
3.Mention dates of admission to the Hospital, Stay etc.