yo The PSSH> Gererad M7aneger C8Icy Coe cor porte PP Beg conod Wet. Rancla! Sub: Eubont $5 on B PRS Predeal OM a Si, Enelesgod Please pond ee Aj poe RS BB OSES gpeesd CA TERA eT SURGE bY Yom wwige, grt chateundals devifzr—~ Thenlar np you ye fats bot 4 : py ot eee dale hyontos pend ex ert SP PO. Rae Rome beBonk nip Bort, keane tole Qanel- AlcAe~ Y3S&2 DD Joov B515— isle No~ UBINOS 49.5 50% eee amratar are Pent FOOD CORPORATION OF INDIA Fon OF APPLICATION FON) CLAMING REFUND OF MEDICAL EXPENDITURE INCURNED IN CONNECTION WITH KIEDICAL ATFENOFRCE AND/ON THEATMENT OF OFFICERSISTAFT OF THE F LAND THEIR FAMILIES Hf Separate form should be used lor each parien ULarests 8S PResAD Fel, RY Ranchs’ 1 ame an Designation of employes (in block atters) 2. Océ in wich employed <_payel ie employees ae cotnod funda {aulec arr ther emolurnent vic shoul be shew a copa enh \ : ~ fer, RO © 4 pine! ely 5, Achia.tesidential adres ate Sam leng chend te, P 6 Hame ofthe patient 8 hisiher relationship to the Athen Ravel's 7 mptoyee (Ii eividren, state age) — comt- shavimseaks De i. (wife) iaca whore We palinnt = gyale Bye pager tal Raa ctl: 1 Dotnigatamsunteaimed PL- 2330 os MEDICAL ATTENDANCE vemptdesyrroncfwensescsonin, DY VIERA oun Li0s nnd me hoeptataspensnyytouich a ay @LLA EYE Mes?) TAL. caTarA ct & Low vishon CEN HAaWwAl NASAR RAM CHI, Fees for consultation idietna tations and ives paid fo) the no. & date of injection and fees pal fer each injection CATARACT FURGE RY. (a) Whether the consultations and /erinjections \ 18 a 2024 ty | Ber 2ory rarae tor paltiealag eal, bacteriological. reduingica! lakers during dlaganosis imuicating of Hospital of laboratory where the erm under taken (a) thew nother he tests were undertaken on the o! authorised medical altend2nt i £0, 1e6 10 that elfen shoul! be attoetied DECLARATION TO BE SIGNED BY THE EMPLOYEE Hat the stalenn! given by me in Us application are ti8 fo the best of my knowledge fon for wim medivel expanses wera incurred in wholly depencing one. falegh onan read” SIGNATURE OF EMPLOYEE Pro@) vuinanennteeineinBD34S2, BS toupoon TAT Hy, A hrree, Blea ao Thre, Bendre fiv eo Peafs egeda piv ante to Ustol enclosures r Yyorns ARy TEs CD) Dis CHarne & = CERN FILATES Oe ca ay Be CHEEP sey (9 Precectyn, jnveta mr Onty Aserpt O97 meng, Treat for silishusbanlsonkdnug tewathoe mate Homootdsnase, CATHRO6 7, SURGERY . 16.0) 2026 ig 1628 2024 Duration of treatment from DETAILS OF MEDICINES PURCHASED st] Cash memo Name of medicines | Quantity Price | Shop trom where io, BOL (in Flock Letters) Rs. P| purchased 2 3 4 5 6 A _—_————_ | encl 1 —— — FOR OFFICE USE Consuttation’Medical “Advice ete \Diet/Aecomordntion ate. Injection charges of nemenvoparation ete A ray'Pathologen test etc Contot menenn Total Pascoe for Baymont Rs. Rupecs. ‘equ Manaran (Res) Assistant Mamayor (Accounts)CERTIFICATE -B {To be complered in the of pation Certificate granted to MISTANSS Mr ec SUFI SACL... DB WieisonDa.ghor att uu SAMSHMAR.PRABAB.. the. PAR’ (To be signed by the medical Officotiincharge oF he ux. DE FAUB BME ce LOSPLTIL. case the hosp 2) That the patient was admitted 19 Hosplat on the advise ation my advice Pps ikea PHaeyg, (NAME OF MEDICAL OFFICER) Oe Vera Bam pe nl mipes b) That the patient has been under treatment af ASERY...CUBET. BYR) and that the under mentioned edicnes aresc ¥ me i the connection were essential ecovery, prevention ef serious deterioration in the nes are pot stocked in the lon of the patient The med (NAME, OF HOSPITAL) 1 {o* supply to private patients and do not include prep for which cheaper subs value are available for preparations which are prim y foods. tolttes or disinfectant NAME OF MEDICINES SYtonsr — Appaem- Pd He Deep ThepiA 5 MA DREP Te - F 5 Olunewh HIT = & 9 ©) That the wnyachons ndministord arervare nol for immunaing oF prophylacte purposes 2 Thatinegainnt suas sutlerrg CATARey CURT RYB.) from nd sas under treatment trom Wi 1014 1 I] 1) rong PTOfe) That the X-ray, Laboratory test snere necessary and were under token on ny alive a {NANE OF HOSPITAL OF LABORATORY) trative bad ‘as required under the rules, was 00! Vite Bratton mle Dhan VIL Hospr 7g, UF AND DESIGNATION OF THE WAL OFFICER INCHARGE OF THE CASE AT THE HOSPITAL hospital and tral tne aces attached nanan of we patent Mixtaun Boalta = Breas De Hosein Medical Suoerniendent hospita/ang |. certty that the patient has been under i that the facilties provided were (he mninnim i yor7 essential fo" the patients treatment MEDICAL SUPERINTENDENT HOSPITAL PLACE 1B Gertie spoleable shouls & Carttheate s catnip wav voy the Medics Officer in all easesBHALLA EYE HOSPITAL Mobile No 8969749533 Hawai Nagar Ranchi 7061015823 Name of the Patient : SHAKUNTALA DEVI uo No. 14341 Age Sq Years sons Name of Surgery : Cataractsurgery L/E (Punco) MP fou. Date OF admission: 13 ]) J24 Name of surgeon: DrVkram Bhalla Date of surgery: 18 11 Fy Condition at discharge - STABLE Date of discharge: 18 1124 POST- OPERATIVE ADVICE: 5 ALAPDROPS PD eve G09 cvnsne THAR PHO are... ofviera anh ater or lo Prttae — ‘ 2TROPLUS/ TROPIA eve drop.....MT aE Tit Aaa Tea... aie aT oer - 10 Fitare Be YoMng 7 =. i , YM se —s- 5 Hug Ra ¢ hee 4 Ou Misa — ar bud Hue REX Cot A e FE] spurpyzco rower 22.500 ar os WAR. [ax] NOzo120008 071 fox) C0s-a014 2020 A zozo12 gy 2028-11 co SF aGa"” AConsart 1)g,g "7 Review Tomorrow at Bhalla Eye Hospital PRECAUTIONS: oy as Pes ere acer are ate oe aft ao, ara a nea ea AT ATE | 215 Pret for ater aris ate ot acm adi air | 3. ame gir rr Anas arg are ara tins, eran ean Sate 5 flere a sere 7H | 4 2o Feit i gem ere seit rat Rr tae ra sem el et | & Fairer fara & aque deh, aig (ory, areas, Bee Patter ar wh Pt aaa Tr aA cH | 6. arr aires ane aie ft THE | 7 srl ae tar ramet | 8 sistent ears serra de, sie ets, et era NTT & Bee we HES Soar # | wie iPr aie gfe Stan eae Hi pe aha rire ae | Or. Vikram Bhalla Im Case of any emergency call 8969749533 , 7061015823 {Regn, no. 63962)Name: SHAKUNTALA DEVI 1 post-operative day Lee -» = Comea- clear = AIC - well formed * OL -in-sity ‘as advised in discharge summary ‘Review after |e days /as required b uip:14371 ate: 30-01-2024 th Ma Si, Bou, Ag py Poy x & f he wy Ay ° Gay Uy ap Laps “po Spay ow x aay Follow-Up. PROCEDURE INVOICE Patient Name: SHAKUNTALA DEVI up ar Mobile: 7008220418 Bhalla Eye Hospital Ftawai Nagar, Soya Ta, Opp Mani Tv Value Besides HP Pete! Pap, Ranch-834003 Phone 596974953, TCR0YSA2 Email: thalaeyefourdation27@gmailcom (GSTIN:ZORQGPHSETEN ZR. Image No: 1721 Imasice Date 18-01-2024 SN Procedure Be ate rate | Gross | Totat 1 Cataract Surgery Left ye re.ot-2024 | 33000 | 33000 | 33000 Gross tow! —_ | 33000 For Balla Eye Foundation =MEDICINE INVOICE GGSTIN 20KQGPB367SNIZR Phone: 8965748533, 7061015823, Email: Bhallaeystoundation2017@gmaitcom Bhalla Eye Hospital Patient Nami "| Hawai Nagar, Satyar Tol, Opp.- Maruti True Value, desides HP Petro! Pump, io: 14371 Ranch 934008 Bobi 7008220418 Invoice No: 0485 Invoice Date: 19:07 2024 sv. | trem Name Pack | Hsn | Baten | expiry | uni J rate | ary | ot | Gross | cast | s@st | Tota! 1 | appRoPs po 10 | 3008 | criasza | 31-07-2026 J nos |azss | 1 fo | aaz2 | ass | ase | ares mi 2 | ropa Smt | ana | nests | 2ecz205]ros ar | 1 fo | atse| ase | 252 | a7 3 [umsousomrment | 3am | aoa | xno | 30-05-2025 ]nos |e | 1 fo |asss {sa |sa | oo 4 | arrsons somt | 3004 | cocaeos | 31082024] nos so | 1 [o | sasr|azr | a2 | 60 | siacerostoperatve |1 | reasr2 | accor | ar-o202}nos |so [1 Jo [se Jo |o so Goggles ‘Terms and Conditions: For Bhalla fye | Gress Tots! 27664 1. Goods once sold wil not be taken back or exchanged. 2 Please check goods deliered before leaving our premises GST Total 1359 3. All disputes subject to Ranchi Jurisdiction only. — : 4. Prescribed Sales Tax declaration wll be given SST Total 1359 Invoice Total 303.85 Vile©: 8969749533 BHALLA EYE HOSPITAL patented CATARACT & LOW VISION CENTRE. Hawai Nagar, Near HP Petrol Pump, Opp. Raha Saudi Bhawen, Solanki Rane Dr. Vikram Bhalla ¢regisrasion No. 63982) MBBS (Kolkata), DN@ (Susrut Eye Foundation, Kolkata) Fellowship (Vitreo-Retina) (Short Term) "Name : SHAKUNTALA DEVI UID: 14371, Age: 59 yearsO months Sex: Female Date: 05-01-2024 @ a a 9. 0 oy is i H/O: OM / HIN / HD / ASTHMA / THYROID ueva < ror < mmHg at 6 6 . pp 7 RIGHT EVE Tf urT ENE seh [ ot [aie | vison sex_[ ot [me [von ae bv jo wa! fee Stet ow bean “Gfetp] A I [Ae a | ee _ : 4 Fetes " Sasdy Cab He De fee ON (Be savin Qo fue Jou —_ 6 Gp mR LH 7 4, Mo -4 —— 4 bur BEX By ps be wm: TIMING : ‘aware WAAR: 1000 AM t0.07.00 PM Monday to Saturday: 10:00 AM to 07:00 PM Vali for 1 Month ‘PAIR: 10:00 AM to 11.00 AM. Sunday: 10:00 AM to 11:00 AM Not for Mecicolegal Purpose