Subject: Application For Medical Reimbursement

Respected Sir,

I __________ working as a _________) at Department of _________. Through this application

letter, I am applying for the medical reimbursement, reference to my employment number
_______.

Due to the criticality, I was in an urgent need to visit the nearby ________ Hospital and get a
checkup done. I had paid total of Rs._______/- ( ______only) against my indoor medical bills.
With this letter, I would request you to kindly reimburse the amount that I had paid for my
treatments. I am herewith enclosing the medical bill, doctor’s prescription and other relevant
record for your kind reference.

I request for an early response from your side. If any other information or detail is needed from
my side, then I can be contacted on _________

Thanking you for your time and consideration.

Sincerely,

XYZ