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reinbement billofor

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Detas:
CPF No: 50032 Thanping ye
Designatrn; Chiey Chemit
Date d retiremnt: 3l.12. 2013
Amant claimed ? ol8 253.56 Houikaishna Mauy
CPP no. -50032
Dase -Innoh 202 4
 Kokilaben Dhirubhai Ambani
hospital &medical research instltute

Every Life Matters

Name: [Link]-MsHaIkrshno Mausya Age:. -years Date:.stel2s

Aug
n Magne Foste (39)

Ps SanjáyPandey
[Link]), D.N.B. (Urology)
Name of Dr.:. Consulanty tfobg Andralogy &
Gender Reássignment Surgery
[Link].: Kokilaben Dhirubhai AmbaniHospital
&Medical Research Institute
KokRabbnbirAA938
Hospital &Medical Resdarch Institute
Four Bungalows,Andheri (W), Mumbai-53. India. Emergency Helpline.: 91-22-4269 9999. Fax: 91-22-4336 6777.
Doctor Appointments: 91-22-4269 6969. EHC: 91-22-4336 6666.
Web: [Link]
 Kokilaben Dhirubhai Ambani Dr. Sanjay Pandey
hospital&medical research lnstltute MBBS,MS (General Surgery)
MCh (Urology), DNB (Urology)
MUMBAI Head -Andrology & Reconstructive Urology
Every Life Matters Consultant - Robotic Urology
Eadourology & Geoder
Reassignment Surgery
Reg No: 2009/01/0058

Date:

Name:

UHID No.:

Presenting Complalnts:

Past History:

(
VItal Signs:

Physical Examination:

-)

(Unit of Mandke Foundation), Four Bungalows, Andheri (W), Mumbai - 400 053, Indla
¿KDAH Appointments: (91-22) 4269 6969 | Accident &Emergency: (91-22) 4269 9999 EHC: (91-22) 4336 6666
Toll-free: 1800 3000 3333 | Fax: (91-22) 4336 6777
9 [Link] A/KokilabenHospital D/KDAHMumbai /kokilabenhospital
CIN: U99999MH1998NPL127767
 Kokilaben Dhirubhai Ambani Dr. Ruchi Shetty
hospital & medicalresearch Institute M.D, EDIC
Consuitant Intensivist
MMCReg No:2005/04/2340
Every Life Matters

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(Unit of Mandke Foundation), Four Bungalows, Andheri (W), Mumbal- 400 053, Indla; Tel, No.: +91 22 3066 6666/3099 9999
Accident &Emergency: +91 22 3091 9191; Appointment: +91 22 3069 6969: TollFree: 1800 3000 3333; Fax: +91 22 3097 2030
Web: [Link] 0/KokilabenHospitalMumbal /KDAHMumbai /kdahmumbai
NABBH CIN: U99999MH1998NPL127767
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The prescribed format having cmployee details and Submission no. has beern designed as belo This
form or a hand written application indicating required details and the original medical billk need to be
submitted to SEE (Separated Employee Establishment ).

OIL AND NATURAL GAS CORPORATION LTD

MEDICAL REIMBURSEMENT BILL FOR RETIREDEMPLOYEE
CPF No:
50032
Name : |DR. HARI KRSHNA MAURYA
Designation: CHIE eHE DMIST
Location:
|ANKLESHWAR
Date of Retirement: 312 2o13
Mobile No. / Telephone No. : 981938IS7 fo22- l 9685429
Medical Claim Submission No. : S$0030314
Amount Claimed : Ry |8255:56
Certified that - (a) the claim is as per actual expenditure incurred. (b) the person for whom expenses
have been incurred is dependent on me.
THiS BlLL IS SEING
CLAMED FoR THE FIRST
TIME
Date: 24hFED 2024 Signature of employee

(Signature) (Signature) (Signature)

/C-SEE i/C- Medical Section /C- PCS Section

(Kindly Attach the Cash Memo /Receipts along with this form)
 vice

charge :
Payme
Card
ls
pY
aben Dhirushai Ambani

Kokilaben Dhirubhai Ambani Hospital

(A Unit of Mandke Foundation)
Andheri(W), Mumbai-53, Phone No: +91 22 42696969

BILL OF SUPPLY
Original
Patient ld : KH1000471566 OPD No. 14360940/1
Age/Sex : Male/ 68Y 11M 30D Bill No OPBL/24239195

Patient Name Mr. Harikrishna Ramdular Maurya Bill Date 16/08/2023 08:58
Consulting Doctor [Link] Speciality CRITICAL CARE M

Referred By Patient Address : A-704 Samarpan Near,Magathane

Telephone ,Exchange Borivali E
Total Discount Net Amount SGST Rate SGST Amount CGST Rate CGST Amount Amount
Service Name HSN/SAC Code Date/Time Service Provider Base Rate Qty

Diagnostics
1.00 1900.00 0.00 1900.00 0.00 0.00 1900.00
REnal Profiles 999316 16/08/2023 08:58 1900.00
999316 16/08/2023 08:58 261.00 1.00 261.00 0.00 261.00 0.00 0.00 261.00
Aúcose Fasting
261.00 0.00 261.00 0.00 0.00 261.00
Glucose Post Prandial 999316 16/08/2023 08:58 261.00 1.00
508.00 1.00 508.00 0.00 S08.00 0.00 0.00 508.00
CRP 999316 16/08/2023 08:58
Complete Blood Count 999316 16/08/2023 08:58 428.00 1.00 428.00 0.00 428.00 0.00 0.00 428.00

CBC)
5.00 3358.00 0.00 3358.00 0.00 0.00 3358.00
Diagnostics(Subtotal)
Total 3358.00

Net Payable 3358.00

Receipt 3358.00
OPREC/24161693/16-AUG-23(By Card swip thrrgh POs 3358.00
machine(interface)- Credit Card No:************5957

THe B[LL S BEING CLAIMED FoR THE ,Bank:Master Card Approval Code:122455)
BillOutstanding 0.00
EIRST TIME
SELF ATTESTED B HARIKRISHNA
Received With Thanks From Mr. Harikrishna Ramdular Maurya an amount of Rs. 3358/
Rs. Three Thousand Three Hundred Fifty Eight And Paise Zero Only
MAUeyA
Niraj Shah
1st Floor East Wing 7 (R&B)
Note: 24th FEB 2 o24
1.0NE Follow up Consultation willnot be charged to the same consultant within 7 Days of Primary Consult.
[Link] Home Collection Service Available for Laboratory Sample Collection, For Home Visit Call +918080022222 /-91 22 42696900
[Link] are requested to collect allpending reports within 60 days from hospital; after which the same will be discarded.
[Link] related to Covid reports, mail to report@ [Link]/022-42699841(Time 10am to 6pm)
CIN No. : U99999MH 1998NPL127767,TAN : MUMM13501F, GSTIN/UIN : 27AAATM4557G1ZH
For making Digital Payment, kindly scan on the Dynamic QR Code refilecting on the digital display (POS machine).
of 1
16/08/2023 09:00
 Fn [hirubhai Aubani

Kokilaben Dhirubhai Ambani Hospital

(AUnit of Mandke Foundation)
[Link] 80 &81, Gr. Flr, R.A. Patwardhan Road, 4 Bungalows
Andheri(W), Mumbai-53, Phone No: +91 22 42696969

TAX INvoICE

Original
Patient ld . KH1000471566 Patient Name Mr. Harikrishna Ramdular Maurya
Age/Sex . Male / 68Y 11M 30D Patient Address A-704 Samarpan Near, Magathane
Telephone ,Exchange Borivali
Consulting Doctor : [Link] PANDEY Bill Date 16/08/2023 09:42
Payer Bill No : OPBL/24239256

Service Name HSN/SAC Code Batch/Expiry Date Manufacturer Base Rate Qty Total Discount Net Amount SGST Rate SGST Amount CGST Rate CGST Amount Amount
Name

Pharmacy
INFANT FEEDING TUBE 7 90183990 K230210684/31/0 ROMSONS 54.47 4.00 217.86 0.00 217.86 13.07 13.07 244.00
ROMSONS GS-4038 1/28
NEEDLE18G 11/2 BD 90183220 3010707/31/01/2 BD 5.36 1.00 5.36 0.00 5.36 0.32 0.32 6.00

NS 0.9% 100ML FLEXIDRIP 30049099 2232523/31/05/2 CLARIS 42.04 1.00 42.04 0.00 42.04 2.52 2.53 47.09
6

PRESSURE MONITORNG 90213900 K220610668/31/0 ROMSONS 306.25 2.00 612.50 0.00 612.50 36.75 36.75 686.00
LINE 100CM M/F ROMSON 5/27
SAFESET [Link] w/o BACK 90183990 23C22K8351/01/ B BRAUN 364.29 1.00 364.29 0.00 364.29 21.86 21.85 408.00
FLOW 4063001 BB 03/28
STERILE WATER 10ML 30049039 2230533/31/01/2 CLARIS 2.57 4.00 10.29 0.00 10.29 0.62 0.61 11.52
OTSUKA 6

SYRINGE10 ML VWITH 90189029 2303504/28/02/2 BD 30.36 4.00 121.43 0.00 121.43 7.29 7.28 136.00
NEEDLE 21 X 1 BD 8

TODAYCEF 3GM INJ (H1) 30049099 DO392210A/30/0 AKUMENTIS 1270.78 1.00 1270.78 0.00 1270.78 76.25 76.24 1423.27
9/24
VEIN O LINE 10CM 90189099 K230610914/31/0 ROMSONS 309.82 1.00 309.82 0.00 309.82 18.59 18.59 347.00
ROMSONS 5/28
VENFLON PRO SAFETY 22G 90183930 3024694/31/01/2 BD 433.04 1.00 433.04 0.00 433.04 25.98 25.98 485.00
X 25MM 393222 BD 6

THE B|LL IS SELE ATTES TED Total 3793.88

Net Payable
BEING QAImEp Neny.
3793.88

Receipt 3793.88

FoR THE IPREC/24072209/16-AUG-23(By Card swip thrrgh POS 3793.88

HARIKRISHNA HAOR9A machine (interface)- Credit ford Nat*******957
FIRST IME ,BankcMaster Card
2qth FE 2024 Bill Outstanding ,Approv9AUSHADH
Room No. 80, &81, BANDARI d.00
Neha Singh Patean
Gr. Floo, R. A. Marg.
Pharmacist - CCounter 2 4 Bungalow, Andhari (W).
16/08/2023 09:42
Mumbai-400 053
 aben hinhhi Ambani

Kokilaben Dhirubhai Ambani Hospital

(A Unit of Mandke Foundation)
Andheri(w), Mumbai-53, Phone No: +91 22 42696969
BILL OF SUPPLY

Original
Patient ld : KH1000471566 OPD No. 14360941/1
Age/Sex :Male /68Y 11 M30D Bill No OPBL/24239196
Patient Name : Mr. Harikrishna Ramdular Maurya Bill Date 16/08/2023 08:59
Consulting Doctor : [Link] PANDEY Speciality : UROLOGY
Referred By Patient Address :A-704 Samarpan Near, Magathane
Telephone ,Exchange Borivali E
Service Name HSN/SACCode Date/Time Service Provider Base Rate Qty Total Discount Net Amount SGST Rate SGST Amount CGST Rate CGST Amount Amount

Doctor Visit Fees

Primary Consultation 999311 16/08/2023 08:59 [Link] PANDI 1500.00 1.00 1500.00 0.00 1500.00 0.00 0.00 1500.00

Doctor Visit 1.00 1500.00 0.00 1500.00 0.00 0.00 1500.00

Fees(Subtotal)
Total 1500.00

TRE BlLL IS BEJNG CLAJMED FoR Net Payable 1500.00

THE FIRST TIMA Receipt 1500.00

OPREC/24161693/16-AUG-23 (By Card swip thrrgh POS 1500.00
SELF ATTESTEP machine(interface)- Credit Card No:***** *****5957
,Bank:Master Card ,Approval Code:122455)
BillOutstanding 0.00

Received With Thanks From Mr. Harikrishna Ramdular Maurya an amount of Rs. 1500/ HARI KRISHAA MAURYA
Rs. One Thousand Five Hundred And Paise Zero Only
2qth fEB 2024 Niraj Shah
1st Floor East Wing 7 (R&B)
Note:

1.0NE Follow up Consultation willnot be charged to the same consultant within 7 Days of Primary Consult.
[Link] Home Collection Service Available for Laboratory Sample Collection,For Home Visit Cal +918080022222 /+91 22 42696900
[Link] are requested to collect all pending reports within 60 days from hospital; after which the same will be discarded.
[Link] related to Covid reports, mail to report@[Link]/022-42699841(Time 10am to 6pm)
CIN No. : u99999MH1998NPL127767, TAN: MUMM13501F, GSTIN/UIN : 27AAATM4557G1ZH
For making Digital Payment, kindly scan on the Dynamic QR Code reflecting on the digital display (POS machine).

16/08/2023 09:00 1 of
 en Dhin1bhai Ambani

Kokilaben DhirubhaiAmbani Hospital

(A Unit of Mandke Foundation)
Andheri(W), Mumbai-53, Phone No: +91 22 42696969

BILL OF SUPPLY

Original
Patient Id : KH1000471566 OPD No. 14360940/1
Age/Sex : Male / 68Y 11 M30D Bill No :OPBL/24239193
Patient Name : Mr. Harikrishna Ramdular Maurya Bill Date : 16/08/2023 08:56
Consulting Doctor . [Link] SHETTY Speciality : CRITICAL CARE M
Referred By Patient Address :A-704 Samarpan Near, Magathane
Telephone ,Exchange BorivaliE
Service Name HSN/SAC Code Date/Time Service Provider Base Rate Qty Total Discount Net Amount SGST Rate SGST Amount CGST Rate CGST Amount Amount

Doctor Visit Fees

Primary Consultation 999311 16/08/2023 08:56 [Link] 1500.00 1.00 1500.00 0.00 1500.00 0.00 0.00 1500.00

Doctor Visit 1.00 1500.00 0.00 1500.00 0.00 0.00 1500.00

Fees(Subtotal)
Total 1500.00

THE BILL IS BEING CLAMEP FoR Net Payable 1500.00

Receipt 1500.00
THE FIRsT TIME OPREC/24161693/16-AUG-23(By Card swip thrrgh POS 1500.00
machine(interface)- Credit Card No:************$957
SELF ATESTED ,Bank:Master Card ,Approval Code:122455)
Bill Outstanding 0.00

Received With Thanks From Mr. Harikrishna Ramdular Maurya an amount of Rs. 1500/ HART KK1 SHNA MAUR yA
Rs. One Thousand Five Hundred And Paise Zero Only
2 qhFEB 2o2 4 Niraj Shah
1st Floor East Wing 7 (R&B)
Note:

[Link] Follow upConsultation will not be charged to the same consultant within 7Days of Primary Consult.
[Link] Home Colection Service Available for Laboratory Sample Collection, For Home Visit Call +918080022222 /+91 22 42696900
[Link] are requested to collect all pending reports within 60 days from hospital; after which the same willbe discarded.
[Link] related to Covid reports, mail to report@[Link]/022-42699841(Time 10am to 6pm)
CIN No. : U99999MH1998NPL127767, TAN: MUMM13501F, GSTIN/UIN : 27AAATM4557G1ZH
For making Digital Payment, kindly scan on the Dynamic QR Code reflecting on the digital display (POS machine).

1
16/08/2023 09.00
 hishi Abami

Kokilaben Dhirubhai Ambani Hospital

(A Unit of Mandke Foundation)
Andheri(W), Mumbai-53, Phone No: +91 22 42696969
BILL OF SUPPLY

Original
Patient ld KH1000471566 OPD No. : 14361499/1
Age/Sex Male /68Y 11M 30D Bill No : OPBL/24240202
Patient Name : Mr. Harikrishna Ramdular Maurya Bill Date 16/08/2023 13:27
Consulting Doctor . [Link] PANDEY Speciality : General Service
Referred By Patient Address A-704 Samarpan Near, Magathane
Telephone ,Exchange Borivali E
Service Name HSN/SAC Code Date/Time Service Provider Base Rate Oty Total Discount Net Amount SGST Rate SGST Amount CGST Rate CGST Amount Amount

Diagnostics
Diagnostic Visit 999311 16/08/2023 12:18 0.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00
Complete Urodynamis 999311 16/08/2023 13:12 7325.00 1.00 7325.00 0.00 7325.00 0.00 0.00 7325.00

2.00
Diagnostics(Subtotal) 7325.00 0.00 7325.00 0.00 0.00 7325.00

Pharmacy
GLOVES POWDER FREE 7.5 40151100 16/08/2023 13:15 114.00 4.00 114.00 0.00 456.00 0.00 0.00 456.00
INCH ENCORE
NS 100OML STERIPORT 30019099 16/08/2023 13:15 110.32 1.00 110.32 0.00 110.32 0.00 0.00 110.32
(AMANTA)
SYRINGE 10 ML WITH 90189029 16/08/2023 13:15 34.00 3.00 34.00 0.00 102.00 0.00 0.00 102.00
NEEDLE 21 X 1 BD
SYRINGE 20 ML PLAIN W/O 90183100 16/08/2023 13:15 40.50 1.00 40.50 0.00 40.50 0.00 0.00 40.50
NEEDLE BD
THEMICAINE 2% JELLY 30031000 16/08/2023 13:15 33.93 2.00 33.93 0.00 67.86 0.00 0.00 67.86

11.00 332.75 0.00 776.68 0.00 0.00 776.68

Pharmacy(Subtotal)
THE SELE ATreSTED Total 8101.68
BILL IS BEING Net Payable 8101.68

CLAIMED FoR THÊ Receipt

IPREC/24072528/16-AUG-23(By Card swip thrrgb Pos
8101.68
8101.68
FIRST TIME HARI KRISHA MAURYA machine(interface)- Credit Card No:****5957
,Bank:Master Card ,Approval Code488594),
24nFE 2024 Bill Outstanding 0.00

Received With Thanks From Mr. Harikrishna Ramdular Maurya an amount of Rs. 8101.68/
Rs. Eight Thousand One Hundred One And Paise Sixty Eight Only
Prafulla D Bhanse
1st Floor East Wing 2 (R&B)

16/08/2023 13:28 1 of 2