The document is a proforma for reimbursement of medical expenses to insured persons. It requests information such as: 1) Whether the case was emergent and admission details. 2) Dates of admission and discharge from the hospital. 3) Accommodation class provided. 4) Details on insurance eligibility. 5) Special ward usage and charges if treated in general ward. 6) Medicine purchase details and test details like X-ray and lab tests. The medical officer of the private institution needs to provide the requested information to process reimbursement for the insured patient's medical expenses.