Get Hptr 6
---): Place of Duty: Name of Patient: Relationship with Employee: Age: Nature of illness: Name of Doctor/Hospital: Period of treatment: From ------------- To-------------------(Certificate issued by the Medical Officer in-charge of the hospital as per enclosed proforma is to be attached) 12. Details of claim: (attach prescription, vouchers, etc. in duplicate) Voucher No. Amount Consultation: Diagnostics/Tests:.
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