MEDICAL REIUMBURSEMENT FOR STATE GOVERNMENT EMPL

PERSONAL DETAILS DOCUME

Name of the Employee 1 Y. Ramana Rao Please select the do
Designation 40 1
Place of Working ZPP. High School, Balayapalli 1
Name of the Mandal Balayapalli 1
Name of the District 3 1
Present Scale of Pay 17 1
Present Basic Pay 29 1
Residential Address H.No. 7-197 1
PS Street 1
Venkatagiri
PIN CODE 524132

PATIENT DETAILS
Name of the Patient 1 Y. Sarala CLICK ON T
Relationship with Employee 8
Age of the Patient 15 Years
Name of the Hospital 159
Category of the Hospital 2
Name of the Treatment Fever
Amount of Hospital Bill in figures (Rs.) 15462
Developed By:
Date of Joing in the Hospital DD-MM-YYYY 01-07-2009 Note: To unprotect
K. Sreenivas Reddythewo
s
Date of Discharge DD-MM-YYYY 10-07-2009 District Educational O
Date of submission of Proposals to DDO DD-MM-YYYY 22-08-2009
Please verify with exp

D.D.O. DETAILS For your valuable sugg

Ph.No. 9848363735 (o
Name of the D.D.O 1 P.Subbarayudu
Designation 7
D.D.O. Place of Working ZPP High School, Balayapalli
D.D.O. Mandal Balayapalli
D.D.O. District 7
ATE GOVERNMENT EMPLOYEES

DOCUMENTS TO BE ENCLOSED
Please select the documents that are enclosed with Bill

CLICK ON THE FOLLOWING LINKS

Letter to the D.D.O.
Letter to the Higher Authorities
Non-Drawl Certificate
Check List for sending Proposals.
Appendix - II
Dependent Certificate.
Developed By:
Note: To unprotect
K. Sreenivas Reddytheworking
sheets from 1 to 6 password:
on deputation at O/oTEACHER
the
District Educational Officer, Hyderabad District.

Please verify with experts before submission.

For your valuable suggestion please contact

Ph.No. 9848363735 (or) ksr_0708@yahoo.co.in
15462
45169
4562
46215
4215
45005
(Rupees Fifteen Thousand Four Hundred and Sixty Two Only)
(Rupees Fourty Five Thousand One Hundred and Sixty Nine Only)
(Rupees Four Thousand Five Hundred and Sixty Two Only)
(Rupees Fourty Six Thousand Two Hundred and Fifteen Only)
(Rupees Four Thousand Two Hundred and Fifteen Only)
(Rupees Fourty Five Thousand and Five Only)
 Date: 22-08-2009
To

The Head Master,

ZPP High School, Balayapalli,
Balayapalli Mandal,
Hyderabad District.

Sir,

Sub: Request to sanction the Medical Reimbursement in repect of SRI. Y. RAMANA

RAO, School Assistant (Maths), ZPP. High School, Balayapalli, Balayapalli
Mandal, APSR Nellore District - Proposals submitted - Reg.

Ref: 1. G.O. Ms.No. 74, M&H Dept., dated: 15-03-2005.

2. G.O. Ms.No. 105, M&H Dept., dated: 09-04-2007.
3. Medical Bills issued by the Doctor concerned.

-o0o-

With reference to the subject cited, I submit here with the Medical Bills with all
the enclosures for Medical Reimbursement for an amount of Rs. 15462=00 (Rupees
(Rupees Fifteen Thousand Four Hundred and Sixty Two Only) only) as my Daughter
named BABY. Y. SARALA who is wholly dependent on me has undergone Treatment for
the desease FEVER in the Recognised Hospital by the Andhra Pradesh State Government
i.e., at YASHODA SUPER SPECIALITY HOSPITAL, SOMAJIGUDA, HYDERABAD during the
period from 01-07-2009 to 10-07-2009 and onward transmit to the higher authorities for
further necessary action in the matter at an early date.

Thanking You Sir.

Yours faithfully,

Enclosures: (Y. RAMANA RAO)

Essentiality Certificate School Assistant (Maths),
Emergency Certificate ZPP. High School, Balayapalli,
Discharge Summary Balayapalli Mandal,
Investigation Report APSR Nellore District.
Dependent Certificate
Medical Bills
Check List
Non-Drawl Certificate
 BACK TO
8-2009
MAIN

RI. Y. RAMANA
Balayapalli

al Bills with all

(Rupees
my Daughter
eatment for
e Government
D during the
authorities for

ully,

RAO)
(Maths),
Balayapalli,
andal,
District.
 GOVERNMENT OF ANDHRA PRADESH
DEPARTMENT OF SCHOOL EDUCATION

From To
The Head Master, The District Educational Officer,
ZPP High School, Balayapalli, APSR Nellore District,
Balayapalli Mandal, Nellore.
Hyderabad District.

Lr. No. __________, Dt: __________ .

Respected Madam,

Sub: Request to sanction the Medical Reimbursement in respect of SRI. Y.

RAMANA RAO, School Assistant (Maths), ZPP. High School, Balayapalli,
Balayapalli Mandal, APSR Nellore District - Proposals submitted - Reg.

Ref: 1. G.O. Ms.No. 74, M&H Dept., dated: 15-03-2005.

2. G.O.Ms.No. 105, M&H Dept., dated: 09-04-2007.
3. Medical Bills issued by the Doctor concerned.
4. Proposals received from the incumbent dated: 22-08-2009
-o0o-
With reference to the subject cited, I submit herewith the Medical Bills with all
the enclosures submitted by SRI. Y. RAMANA RAO, School Assistant (Maths), ZPP. High
School, Balayapalli, Balayapalli Mandal, APSR Nellore District for your kind sanction of the
Medical Reimbursement for an amount of Rs. 15462=00(Rupees (Rupees Fifteen
Thousand Four Hundred and Sixty Two Only) only) as his Daughter BABY. Y. SARALA
who is wholly dependent on him has undergone Treatment for desease FEVER in the
Recognised Hospital by the Andhra Pradesh State Government i.e., at YASHODA SUPER
SPECIALITY HOSPITAL, SOMAJIGUDA, HYDERABAD during the period from 01-07-2009
to 10-07-2009 and onward transmit to the higher authorities for further necessary ction
at an early date.

Thanking You Madam.

Enclosures:
Essentiality Certificate
Emergency Certificate Yours faithfully,
Discharge Summary
Investigation Report
Dependent Certificate
Medical Bills
Check List
Non-Drawl Certificate
 BACK TO
MAIN

icer,
ellore District,
Nellore.

SRI. Y.
alayapalli,
ed - Reg.

l Bills with all

, ZPP. High
anction of the
fteen
. Y. SARALA
ER in the
HODA SUPER
01-07-2009
essary ction

hfully,
 NON DRAWL CERTIFICATE

(As per instructions issued in C & DSE, A.P., Hyderabad Procs. Rc.No.
8878/D3-4/2009, dated: 02-09-2009)

This is to certify that, the amount of Rs. 15462=00 (Rupees

(Rupees Fifteen Thousand Four Hundred and Sixty Two Only) only) is
being claimed now in this bill by SRI. Y. RAMANA RAO, School Assistant
(Maths), ZPP. High School, Balayapalli, Balayapalli Mandal, APSR Nellore
District has not been paid previusly towards Medical Reimbursement in
respect of his Daughter named BABY. Y. SARALA age (15) Years who has
undergone the Treatment for the desease FEVER during the period from
01-07-2009 to 10-07-2009 in the Recongised Hospital by the Andhra
Pradesh State Government i.e., at YASHODA SUPER SPECIALITY
HOSPITAL, SOMAJIGUDA, HYDERABAD as per the records available
regarding the Medical Reimbursement defined under the Government
Medical Attendance Rules, 1972

A note to that effect has also been made in the records of the
school.

Signature of the Signature of the

Government Servant. Drawing & Disbursing Officer.
BACK TO MAIN
 CHECK SLIP FOR SENDING MEDICAL REIMBURSEMENT PROPOSALS

1 Name and Official Address of the Teacher SRI. Y. RAMANA RAO

School Assistant (Maths)

ZPP. High School, Balayapalli,

Balayapalli Mandal,

APSR Nellore District.

2 Dates of Treatment From: 01-07-2009 To: 10-07-2009

YASHODA SUPER SPECIALITY HOSPITAL,
3 Name and Address of Hospital
SOMAJIGUDA, HYDERABAD

4 Whether Private or Government? PRIVATE

Whether the proposal is received in the Head

5 Office within a period of six months from the YES / NO
date of discharge?

Whether Appendix – II attested by the Head

6 YES / NO
of the Office is enclosed?

In case of Treatment at Recognized Hospital /

7 NIMS / SVIMS whether Emergency Certificate YES / NO
enclosed?

Whether Essentiality Certificate mentioning

the amount of expenditure for the Treatment
8 signed by the Doctor who treated and YES / NO
attested by the Authorized Medical Agency is
enclosed?

Whether the bills for the amount mentioned

9 in the Essentiality Certificate attested by the YES / NO
Doctor who treated /A.M.A. are enclosed?

Whether the Discharge Summary of the

10 YES / NO
Patient enclosed?

In case of retired teachers whether the copy

11 Not Applicable
of the Pension Payment Order is enclosed?

In case of dependents above the age of 18

years, unemployment and Dependency Not
12
Certificate counter signed by the Head of the Applicable
Office is enclosed?
 Signature of the Signature of the
Government Servant Head of the Office
ALS BACK TO MAIN

10-07-2009
OSPITAL,
re of the
the Office
 APPENDIX – II
APPLICATION FOR CLAIMING REFUND OF MEDICAL EXPENSES INCURRED IN CONNECTION WITH
MEDICAL ATTENDANCE AND TREATMENT OF GOVERNMENT SERVANT AND THEIR FAMILIES
Name, Designation & Section of Government Servant
1 SRI. Y. RAMANA RAO
(in block letters)
SCHOOL ASSISTANT (MATHS)
2 Office in which Employed ZPP. High School, Balayapalli,
Balayapalli Mandal,
APSR Nellore District.
Pay of the Government Servant as defined in F.Rs.
3 and other employments which should be shown 14860-39540 / 14860
separately
4 Place of Duty ZPP. High School, Balayapalli,
Balayapalli Mandal,
APSR Nellore District.
Full Residential Address with door number, name of
5 H.No. 7-197,
the Mohalla and District
PS Street,
Venkatagiri.
PIN - 524132
Name of the Patient, his/her relationship to the
6 Government Servant, in case of children state age Baby. Y. Sarala, (Daughter)
also
Aged 15 Years
Yashoda Super Speciality Hospital, Somajiguda,
7 Place at which the patient fell ill
Hyderabad

8 Nature of illness and its duration FEVER

Details of amount claimed, cost of Medicines From: 01-07-2009 To: 10-07-2009

purchased from the market/ list of Medicines
9 purchased with cash memos, and the Essentiality List of Medicines in detailed
Certificate should be attached each in duplicate
and
signed
Essentiality Certificates are enclosed

10 Total amount claimed Rs. 15462=00

(Rupees Fifteen Thousand Four Hundred and

Sixty Two Only)

11 List of Enclosures Essentiality Certificate

Emergency Certificate
Discharge Summary
Investigation Report
Dependent Certificate
Medical Bills
Check List
Non-Drawl Certificate
 I here by declare that, the statements in this application are true to the best of my knowledge and belief
and that the person for whom Medical Expenses were incurred is a member of my family as defined under the
Govt. Servant Medical Attendance Rules and wholly dependent upon me.

Signature of the Signature of the

Government Servant Head of the Office
 BACK TO
MAIN
CONNECTION WITH
THEIR FAMILIES

S)
li,

li,

ospital, Somajiguda,

10-07-2009

enclosed

Four Hundred and

te
te

e
my knowledge and belief
as defined under the

gnature of the
ad of the Office
 DEPENDENT CERTIFICATE GIVEN BY THE GOVERNMENT SERVANT
(As per instructions issued in C & DSE, A.P., Hyderabad Procs. Rc.No.
8878/D3-4/2009, dated: 02-09-2009)

I, SRI. Y. RAMANA RAO, School Assistant (Maths), ZPP. High

School, Balayapalli, Balayapalli Mandal, APSR Nellore District, do hereby
declare that, BABY. Y. SARALA, age (15) Years is my Daughter and has no
property of income of her own and that, she is wholly dependent on me only,
she is also not a Employee or Pensioner

Signature of the Signature of the

Government Servant. Drawing & Disbursing Officer.
BACK TO MAIN