Get Form Of Application For Medical Claim - Assam University

This guide provides clear instructions for completing the Form Of Application For Medical Claim at Assam University, ensuring users can easily navigate the process online. Follow these steps to submit your application efficiently.

Follow the steps to complete your medical claim application online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling in your name and designation in block letters. Indicate your marital status and if married, mention where your partner is employed.
3. Provide the name of the office where you are employed.
4. Enter your pay and any other emoluments separately as defined in the Fundamental Rules, followed by your place of duty.
5. Fill in your actual residential address.
6. Specify the name of the patient along with their relationship to you, and the place where the patient fell ill.
7. Detail the amount claimed, including costs for consultation, tests, and medicines. Attach the necessary cash memos and essentiality certificates. List the names, quantities, prices, and total amounts for each medication.
8. Indicate if a consultation with a specialist was conducted.
9. Calculate and enter the total amount claimed.
10. Provide your bank account number for the reimbursement process.
11. Sign the declaration confirming that the statements made in the application are true and that the patient is wholly dependent on you. Also, include the date and your signature.
12. If applicable, include the certification from the medical officer detailing the treatment received and the admissible medicines or tests involved.
13. Lastly, save your changes, then download, print, or share the form as needed.

Start filling out your medical claim application online today to ensure prompt reimbursement.