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A medical reimbursement form is used to claim back out-patient medical costs, such as doctor visits, medicines and tests, under a company's medical allowance or OPD benefit. It is paid by the company through payroll, not by the group insurer, and tracks the employee's annual limit.
MEDICAL REIMBURSEMENT CLAIM FORM (OPD)
| Employee Name | |
|---|---|
| Employee ID | |
| Department | |
| Designation | |
| Reporting Manager |
| Annual Limit (₹) | Claimed So Far (₹) | This Claim (₹) | Balance After Claim (₹) |
|---|---|---|---|
| [Amount] | [Amount] | [Amount] | [Amount] |
| Bill No. | Bill Date | Patient Name | Relationship | Doctor / Pharmacy / Lab | Nature of Expense | Amount (₹) |
|---|---|---|---|---|---|---|
| [Bill No.] | [DD/MM/YYYY] | [Patient Name] | [Self] | [Provider] | Consultation | [Amount] |
| [Bill No.] | [DD/MM/YYYY] | [Patient Name] | [Spouse] | [Provider] | Medicines | [Amount] |
| [Bill No.] | [DD/MM/YYYY] | [Patient Name] | [Child] | [Provider] | Diagnostic Test | [Amount] |
| Total | [Amount] |
I certify that the above expenses were incurred by me for myself or my eligible dependants, that original bills and prescriptions are attached, and that I have not claimed these expenses under any insurance policy or from any other source.
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Medical reimbursement is a company-paid allowance for routine OPD costs, processed through payroll. Mediclaim is group insurance that pays for hospitalisation through the insurer or TPA.
Tax treatment depends on current income-tax law and how your salary is structured. Check with your payroll team or tax adviser.
Most company policies require a doctor's prescription for medicine bills. Check your company's reimbursement policy.