Medical Benefits Claim Slip HR
Medical Benefits Claim Slip
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Employee Name |
John Smith |
ID |
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Department |
Contact |
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Date of Visit |
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Doctor / Clinic / Hospital Name |
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Reason for Visit |
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Total Amount Claimed |
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Insurance Provider |
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Policy Number |
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I hereby declare that the information provided above is accurate to the best of my knowledge and that the medical expenses were incurred by me or my dependents. I understand that any false claims may result in disciplinary action. |
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[Employee Signature] |
[Date] |
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Received by |
[HR Name and Signature] |
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Processed by |
[HR Name and Signature] |
