*CPF/STAFF No.

The Claim submited i_ genyine )

*MEDICAL CARD utaljekos
*PHONE/MOBILE NO. Signature of Applicar
9312-t-32s2
10. List of enclosures

Ihereby
DECLARATIONTO BE SIGNED BÝTH¾ EMPLOYEE os1otfJe 2-est
deciare that statements in this application are true to best of
expenses were incurred is wholly depedent my nowledge and the person fof whom
upon me.
Name &8Gature
Wsallekis
Employee withall
Designation oh
Date
/6/2»24t
TO BE FÍLLED IN BY THE APPLICANT
WBIN KBank Ac. No.
Treatment for : Selt/Vitet
Name and Adtressof BankédieAkelig
Name of Disease - Duration: From.
DETAILS OF MEDICINES PURCHASED
S Cash Memo Name of Medicines Price
Qty. Shop from which
No. No. & Dt. (IN BLOCK LETTERS) Rs. P. purchased RemarkS

3d
Ges

FOROFFICE USE
1 Consultation/Diet
2. Injections/Medical Advice etc.
3. Nursing &accommodation
4 Confinement, operation etc.
5. X-ray, Pathological Test etc.
6 Cost of medicines

PASSED FOR

Rs.. ..(Rupees...

Asstt. Manager (Accounts) Asstt. General Manager (A/cs)

Officer Cat. /Officer Cat. I Officers/Staff/Retired Staff Cat. Il\/Staff Cat.

Debit 5.150-'B/5.150'C! IV
15.982
16.982
Stamp
Received the sum of Rs. Revenue

Signature
*Madatory Fields
 incurred in connection with:
Form Ho.y
Refund of Medical Expenses the
Appllcationfor
Claiming
troatnent of officers/Staff of the Food
Corporation of India and their Families. Medica1
Formof
Attondenceand/or each patient)
should be used for
(N.B. :- Separate form
Employee.
of the Retd.
Name& Designation
1. (IN BLOCK LETTER),

*pate of Retirement
(a)
time of retirement
Division/Place in which posted at the
+ DP + DA = Total
BP
employee at the time of retirement
3 (i) Basic Pay of the Retd.
(i) Deduction Towards MHS at time retirement. Se3ke-ielsheuied)
Place to aval facilty M el
5
*Actual residential Address

Name of the patient self/spouce

Place at which patient fell ill
7

8
XDetails of the amount claimed

MEDICAL ATTENDANCE:
(a Fees for consultation, indicating :
Officer (1)
(b) The name and designation of the Medical which
consulted and the hospital or dispensary to (3)......Rs.....4).......Rs.
attached.
fee paid
(C The number and dates of consultation and the
for each consultation.
for
(d) The number and date of injections and the fee paid
each injection.
(e) Whether consultation and or injections were had at the
Officer
hospital and the consulting room of the medical
or at the residence of patient.
radiological
(a Charges for pathological, bacteriological, diagnosis,
or other similar tests undertaken during
indicating:
where the tests
(b) The name of the hospital or laboratory
were undertaken, and
of the
(c Whether the tests were undertaken onthe advice that
certificate to
authorised medical attendant. If so, a
effect should be attached.
from the market (List of the
i) Cost of medicine purchased essentiality certificate
medicines, cash memos, and the
should be attached).
HOSPITAL TREATMENT
I.
CONSULTATION WITH SPECIALIST

Ofiçer pther than the authorised

Fees paid to specialist or a Medical
58AL
medical attendant indicating k Medical
designation of the Specialist in
(a) The name and to which attached.
Officer consulted and the hospital
consultations and the fee charged
for
(b) Nos. and dates of
each consultation.
the hospital at the con
(c) Whether consultation was had at Medical Officer or the
specialist or
sulting room of the
residence of the patient.
Medical Officer was consulted
(d) Whether the Specialist or
authorised medical attendant.
on the advice of the

(") Mandatory Field. Maneeshunas

 DR GUPTA CLINIC
ME.DICAL. &EYE CARE CENTRE 6 u
Name:
Age Sex:

Home Collection facility aiso available (1-2 km) Ph: 9717911813, 8586933637
*LAB FACILITY:
KALKAJI, N.D.-19 Email: drguptaclinicnlab@gmail.com
DR GUPTACLINIC: 5, DDAFLATS, CENTRAL MARKET,
 DR, GUPTA CLINIC
MEDICAL & EYE CARE CENTRE
5, Central Market, DDA Flats, Kalkaji, New Delhi - 110019
Mobile : 8586933637, E-mail : drguptaclinicnlab@gmail.com
No. 827
Dated. Ds|Aoy
Receioed with thanks from .nQ....aAs..Ssallek%.74)2,.
the sum of R$. ..Coskd.
..By Cash fCheque
for Payment......ne...h..om.
Total Cost..... .Amount Recd. .Balance due.....
For Dr. Gupta Clinic d Lab
Rs.
CONSULTATION TIMINGS : DAILY (6.00 P.M. - 8.30P.M.) SUNDAY (By Appointment only)
*LAB FACILITY DAILY (8.00 A.M. 12.30 P.M. &5P.M. -8.30 P.M. SUNDAY (8A.M. -12.30 PM)
MOBILE: 8586933637 *Home Collection facility also available (1-2 Km.)
 Shroff Eye Centre 100 FOUR
GENERATIONS
YEARS IN EYE CARE
a vision of excellence NABH

www.shroffeyecentre.com |E-mail:- sec@shrofeye. in J9910956780 (I50 9001I :2015 CERTIFIED)

Prescription
Patient ID 230362 Visit Date 07/May/2024
Patient Name Mr. SATISH W. SALPEKAR Age/Sex 77 yrs / M
Payor Name FOOD CORPORATIONOF INDIA (FOCI) - Contact No. 9312232952
Patient Address 131, AARAVALIAPTS., ALAKNANDA
Present Complaints
WATERING FROM RE.

Corrected Corrected CCT CCT

/Method (|OP) IOP Time IOP(RE) IOP(LE) OP(RE) 1OP(LE) (RE) (LE)
NCT 09:12 15 11 15.9 |12.1 534 530

Diagnosis
PSEUDOPHAKIA in Both Eyes
GLAUCOMA SUSPECT in Both Eyes
COMMON CANALICULAR STENOSIS in Right Eye
Rx
0.3% + SODIUM PERBORATE + DEXTRAN + GLYCERIN 1
1. EYEMIST FORTE EYE DROPSIHYDROXYPROPYLMETHYLCELLULOSE
one drop four times a day for 6 Months in both eyes
Advised Investigations
SYRINGING -0 u Seuy
Doctor Remarks
Warm compress
- limitations explained
RE DCR with intubation with lid tightening under LA
Plan of Care :
NIL AGM FOR NOW

Next Review SOS.

Doctor's Signature

DR. MANEESH KUMAR

OUR CENTERS Kaushambi

Gurugram 8826263999, 0120-44 10999
Connaught Place 9650588828, 0124-4709999
Kailash Colony 9667042345, 011-41510906
9109780
 Page 1of i

E Shroff Eye Centre 100 FOUR

GENERATIONS
a vision of excellence
ssursyt

105 a Kran (1 Foor' G

A unit of Shroff Ere Centre LLP

Bill
Bill No SECO1124-250PO9182 Bill Date
Patient Name Mr. SATISH W. SALPEKAR Patient ID 23482
Age Sex-DOB 77 Yrs iM Consutant DR. MANEESH KMAR
FOOD CORPORATION OF INDIA (FC) Wobiie No 81223262
Payor Name

Service Code Service Name Met Ant

Sr.No.
1 CONSULTATION CHARGES-CONSULTANT 350 00

2 REFRACTION
INDIRECT OPHTHALWOSCOPY 7700
3 64
NON CONTACT TONOMETRY 5800
87
90 D LENS EXAMINATION 58.00
91

Amount 52900
Net Amount In (Words) Rupees Five Hundred And Eighty-Nine Oriy. Total
Patient Amount 58900
Paid Amount by Patient 589 00
Payor Amount

Pay Typ Cha/Ref.No

Receipt Date Receip| No Deposit Type
B Time Paid Cash 589
07May2024 9585

FOR:SHROFF EYECENTRE
Patient l Attendant Prepared by

MR. VIKAS SHARMA AuthuttzeSignatory

Deln

http://192.168.10.243:7878/OPDBill.aspx?Billld=358868&Branchld-1&BillingCom... 07/05/2024

more that 10 years.

Certified that I am practising medicine for ntral
 Pagel of i

Shroff Eye Centre 100|GENERATIONS

FOUR
YEARS IN EYE CARE
a vision of excellence
www.shroffeyecentro.com I E-mall: sec@shroffeyo, ln (ISO 90oI: 2015 CERTIFIED)
A-9, Keilash Colony, New Delhl- 110 048 Ph. : 991098078C
105. "Surva Kiran (1st Floor), 19, K.G. Marg, New Dolhl - 110 001, Ph. : 9667042346
. 110, Commercial Plaza, Bestech Chambers, B-Block, Sushant
Lok, Phaso-l, Guruaram - 122 009 Ph. : 9060608828
509, K.M.Trade Tower, Adjacent to Radisson Blu Hotel, Sector14, KaUshambl, Ghaziabad-201010 Ph, : 0020203999
"
A unit of Shroff Eye Centre LLP
LLP vlde LLPIN ACG - 2734 datad 28th March, 2024
/88 of 1968 and 1302 of 1994 ) hus boon convertud Into Shroff Eyo Centre
shroff Eye Centre (Firm Registration No. 1368

Bill
SECO1\24-25\\NV9198 BillDate 07/May/2024 09:41 AM
BillNo
Mr. SATISH W. SALPEKAR Patient ID 230362
Patient Name
|77 Yrs /M Consultant DR. MANEESH KUMAR
Age/Sex - DOB
CASH PATIENTS Mobile No 9312232952
Payor Name
Net Amt.
Sr.No. Service Code Service Name
500.00
1 S-149 SYRINGING

Total Amount 500.00

Net Amount In (Words) Rupees Five Hundred Only.
Net BillAmount 500.00
Paid Amount by Patient 500.00

Pay Type Chq/Ref.No Amount

Receipt Date Receipt No Deposit Type
Cash 500
07/May/2024 9599 BillTime Paid

FOR:SHROFF YE CENTRE
Patient| Attendant Prepired by

MR. VIKAS SIHARiMA Authorizedsignatory

New Deih

http://192. 168.10.243:7878/OPDBill.aspx?Billld=3588888&Branchld=1&BillingCom... 07/Os/2024

 RETAIL INVOICE/ CASH MEMO
SHARMAMESICOS
CHEMIST & DRUGGISTS
G02874
(M) 98102T3700|
986A 540
Emallh shmedlcos@gi FREE
UNIQUE PLACE FOR QUALITY MEDICINES
New Delhi-19
Shop No 4Cental Market DDAFlats, kalkal, DLNo, 38(1308) 20209,21
E NO-07AOCPK9924P1ZA Date:
CaahMemo No.
136 08/05/2024 HOME
P.A. Name: SATISH SALPEKAR
Pr. by "pr.8vt Dr.
Address :

DESCRIPTON BATCHEXPIRYRATERDELIVEXY
AMoUNT
OTY PKa,
EYENISTFORT EYEDROP ENRAFS4465 11/28 279.00 279.00
1

MINIMUM

AMOUNT

I00/Rs.
ChST : 14.9S
ssiM. ST NCET WELL SOON
249,11 X12 29.96 S$ST : 14.95
TOTAL AMT: 279.00
Rs. Amt. (N8nt(R/O) 279.00
Net
ONt charged.
Medicdne once sold wilt not be taken back without Bl.
Loose tabBet wil not be retunn,
Subject to Delhi Jurisdiction.
NOTE: Pase oNsult the doctor befme use he medine Simtture
h-nA NAGCR (44

3-|2-2008

.34,27G|
Ra. 30,36o|
(;3:2232-452
 datod 0.12.2016 &
EP1?201623 0ssued trom File No LP4(06)/2016
sCL HQRS New Delhi Circula No
14.07.2021

Manage)(G)is lound
that Sh. Satish WasudeySalpckar (Ex
Aftercaretul examination, it is cotitied Hypertenslon& Cataracts
to be sutfering trom disesases Heart ailments &

period of Three Years,.

He requires regular treatment for a

Dated: 03.04.2023

"HMedtcal onsultant
frA FI HasNew Delhi

110001/New Delhi 10001

REIMBURSEMENT PURPOSE:
NAME OF DISEASE FOR
Hypertension.
1. Heart ailments &
2. Diabetes mellitus
Paralysis/Cerebrovasular attack (including TIA)
3.
4. Thyroid Disorders
5. Kidney Disorder
Bronchial Asthma
6. Cancer/Malignant Tumors
7.
8
Haemolytic Disorder
9. Tuberculosis Arthritis
Arthritis &(OA)Osteo
10. Rheumatoid
11, Osteoporosis
12. Thalassemia
Disease
13. Chronic Liver including Parkinson's
Disease Retinopathy, Retinal
14. Neurological
Disorders
Diseases) Cataracts, Diabetic
like Degeneration),
Diseases (Eye Glaucoma
15. Ophthalmological Related Macular
Detachments, ARMD (Age of Prostate)
Prostatic hyperplasia/ Benign enlargement
16. BPH/BEP (Benign
including Depression.
17. Psychiatric Dissorders

period of treaieIt.
reguired leave during that 10 vears.
atient did not ral
 System Version 4.0.0
Jeevan Pramaan-Digital Life Certificate

certificate.
Thank youfor submitting digital life
Pramaan id 1358735461 for ppo DLCPMO0039641
1)
Pramaan id 3167025269 for ppo DLCPMO0033125.
2)
certificate on the portal
Youcan view your life Pramaan id.
jeevanpramaan.gov.in by giving
Salpekar
Pensioner Name:Satish Wasudev
:2023-11-10 11:32:37
Registration Date andTime
Cose

of treatment.
That the patient did not required leave during period 10 years.
medicine for more that
Certified that Iam practising
 to No, (11)/(4)

completodin the c499 of a palient who is not adnitled lotheloplal)

o be

fah))))hhs)i2M)MBBRab)baabpHas t l
tf
(#) 4B1nnnya)unmwwgnfba
ehnyel and
Iuebyolly hal ave
receivedin cash Ms.....Zt
patien/at iy consuliation io9m
(ta) f t 14f,,,,».,Wy)mr
navanoa/

That Ihavg charggd and racelvgd in Cash H9.

Intra-muScular injections on..

for lmunlslng o prophylaollo pupo9dn

That the injections sdninigtored werg hot

Anil hal he
oom/outalle lhe bopilal hours dlerlnalg
under y treatmenl al my oon9ullnu teOvery/povonlon of holous
Thal the pafignt has begn by mg in tthis connegtion were e999nlal lorthe Al(l9 ho
lospilal lorsuDply lo prVAle whleh Arg
undgrngntiongd 9dicings prgsoribedmedicing9 Ate hol locked in lhe dispensary/Gov, AVallable OF prapatAllon
the patient, The Are
on in the conditionofpreparations suslenangeof equal therOpeullo value
to which cheaper
include proprietarY
primarlly food toilgts or disintgction, Priea
Nane of Medicine Oly
Oty Prioe
S.No. Narne of Medicings

(3) f zf
Sulfgring
That thg natignt is/wS
frorn.

That thepatient is/was not given pretnalal tr9alment,

ieuo49A1y Al
whichon gxt)enditure of 9,l3):0u)a)11:813)W31: WG IhUnGd wele
Thhat thg X-Any laboratory t9st gte, for /Hospltal/Privalg Cilnio.
Werg urdertaksn on my adyico at Govt
iShIoeeelslcosulrn
hat irgfgrrgd that patient to
hospitalisation,
That thg patignt did not reyyirg i..

Certtisdtthat the disg9s9 Was otof thg prolonggd trostment.,

.WAs GOnsullgd by, Ihe palionl on ny Alvice an
ReceIvgd fis,A1Afeyg na
the cansutation was gss9ntial lor tho sfsyrocovary of the patisnt,
ns Hnout pallgnt
Thst ths patisnt ha$ (99s01sh)ls charnCSof r9cov9ry if th ls lronlgd
G969ntial tor theto60V0ry of lhe paliont,
Thst thg 1rgstrrngnt 9z9s6 o tho prosribgd poiod of 19 days vIss
(4)
autholsgd lhe puohags lym the chéyibt
That ths fAlurg/ydst old not bs disponssd in tho Hospilal and
pormittod lo lo so,
Certifssd that 1arm pradising|llopathi systøm of nsdical and Iam
That ths atisrt did not requirg lgsvg during period f tr9alngnl.
Cortifist that iam pracAising gdicing 1or mors th1 10 ys9rs