MEDICAL REIUMBURSEMENT FOR STATE GOVERNMENT EMPLOYEES PERSONAL DETAILS

Name of the Employee Designation Place of Working Name of the Mandal Name of the District Present Scale of Pay Present Basic Pay 1 36 ZPHS KAVUR CHILAKALURIPET 7 17 29 H.No. 16-1-178/A/9 Residential Address Hari Puri Colony Hyderabad PIN CODE 500072 G.VENKATESWARLU

DOCUMENTS TO BE ENCLOSED
Please select the documents that are enclosed with Bill
Essentiality Certificate TRUE Emergency Certificate TRUE Discharge Summary TRUE Investigation Report. TRUE Dependent Certificate TRUE Medicine Bills TRUE Check List. TRUE

Non-Drawl Certificate TRUE

PATIENT DETAILS
Name of the Patient Relationship with Employee Age of the Patient Name of the Hospital Category of the Hospital Name of the Treatment Amount of Hospital Bill in figures (Rs.) Date of Joing in the Hospital Date of Discharge Date of submission of Proposals to DDO 1 8 15 Years LALITHA SUPERSPECIALITY, GUNTUR 2 Fever 20000 DD-MM-YYYY DD-MM-YYYY DD-MM-YYYY 01-07-2009 10-07-2009 22-08-2009 Y. Sarala

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.
Note: To unprotect the sheets from 1 to 6 password: TEACHER

Developed By:
K. Sreenivas Reddy working on deputation at O/o the District Educational Officer, Hyderabad District.

D.D.O. DETAILS
Name of the D.D.O Designation D.D.O. Place of Working D.D.O. Mandal D.D.O. District Khairthabad 7 1 S. Gurunadha Rao 7 Govt. High School, Begum Bazar

Please verify with experts before submission. For your valuable suggestion please contact Ph.No. 9848363735 (or) ksr_0708@yahoo.co.in

Date: 22-08-2009 To The Head Master, Govt. High School, Begum Bazar, Khairthabad Mandal, Hyderabad District. Sir, Sub: Request to sanction the Medical Reimbursement in respect of SRI. G.VENKATESWARLU, School Assistant, ZPHS KAVUR, CHILAKALURIPET Mandal, Hyderabad 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.G.O.Ms.No. 68 HM & FW dated:28/03/2011 -o0oWith reference to the subject cited, I submit here with the Medical Bills with all the enclosures for Medical Reimbursement for an amount of Rs. 20000=00 (Rupees (Rupees Twenty Thousand and Zero 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 LALITHA SUPERSPECIALITY, GUNTUR 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: Essentiality Certificate Emergency Certificate Discharge Summary Investigation Report Dependent Certificate Medical Bills Check List Non-Drawl Certificate ( G.VENKATESWARLU) School Assistant, ZPHS KAVUR, CHILAKALURIPET Mandal, Hyderabad District.

GOVERNMENT OF ANDHRA PRADESH DEPARTMENT OF SCHOOL EDUCATION From The Head Master, Govt. High School, Begum Bazar, Khairthabad Mandal, Hyderabad District. To The District Educational Officer, Hyderabad

Lr. No. __________, Dt: __________ . Respected Madam, Sub: Request to sanction the Medical Reimbursement in respect of SRI. G.VENKATESWARLU, School Assistant, ZPHS KAVUR, CHILAKALURIPET Mandal, Hyderabad 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 22-08-2009 dated: 5.G.O.Ms.No. 68 HM & FW dated:28/03/2011 -o0oWith reference to the subject cited, I submit herewith the Medical Bills with all the enclosures submitted by SRI. G.VENKATESWARLU, School Assistant, ZPHS

KAVUR, CHILAKALURIPET Mandal, Hyderabad District for your kind sanction of the Medical Reimbursement for an amount of Rs. 20000=00(Rupees (Rupees Thousand Twenty

and Zero 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 LALITHA SUPERSPECIALITY, GUNTUR 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. Date of treatment From From From From Thanking You Madam. Enclosures: Essentiality Certificate Emergency Certificate Discharge Summary Investigation Report Dependent Certificate Medical Bills To To To To

Yours faithfully,

Check List Non-Drawl Certificate

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. 20000=00 (Rupees (Rupees Twenty Thousand and Zero Only) only) is being claimed now

in this bill by SRI. G.VENKATESWARLU, School Assistant, ZPHS KAVUR, CHILAKALURIPET Mandal, Hyderabad 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 LALITHA SUPERSPECIALITY, GUNTUR as per the records available regarding the Medical Reimbursement defined under the Government Medical Attendance Rules, 1972 It is Certified that this is the . Spell of the treatment for the disease mentioned. A note to that effect has also been made in the records of the school.

Signature of the Government Servant.

Signature of the Drawing & Disbursing Officer.

CHECK LIST (Vide Rc No.8878/D3-4/2009,Dt.02-09-2009 of C & DSE AP, Hyderabad)

SRI. G.VENKATESWARLU School Assistant
1

Name and Address of the employee Employee code

ZPHS KAVUR, CHILAKALURIPET Mandal, Hyderabad District.

If Retired a)Date/Year of Retirement b)Designation c) P.P.O.NO

School Assistant ZPHS KAVUR, CHILAKALURIPET Mandal, Hyderabad District. cell no. 01-07-2009 To: From: From: To: From: To: From: To:

Communication of the Applicant Address For all purposes with cell no.

10-07-2009

Dates of Treatment

Name and Address of Hospital

a)Whether Private Hospital (or) Recognized Hospital b)Whether referral Letter Produced (or) Recognized orders to be enclosed along with the proposals

LALITHA SUPERSPECIALITY, GUNTUR RECOGNISED YES / YES / YES / YES / NO NO NO NO

Whether the Medical Reimbursement Proposal sent with in 6 Months from the Date of Discharge Whether the Following are Enclosed 1)Appendix-II duly attested by the Head of the office/DDO 2)Emergency Certificate 3)DischargeSummary 4)discharge summary 5) Non drawl Cerficate

YES / YES / the authorized doctor, who

NO NO

6)Essentially certificate, attested by 7 undertakes treatment

YES /

NO

7)If the Patient is dependent on the Govt.Employee-Un Employee crfificate and dependency certificate are to be enclosed with the Medical Reimbursement Proposals 8)In case of the dependents of deceased Govt.Employee/Retired employee whether legal heir certificate in enclosed (or) not. 9)Whether the Medical reimbursement proposal is prepared and submitted with reference to G.O.Ms.No.74 H.M. & FW(K1) Dept. Dt. 1503-2005 and G.O.Ms.No.60 HM &(K1) Dept.Dt 09-04-2007 and also G.O. Ms No 180 dt.11-05-2006. 8 Whether the medical Reimbursement claim is processed throught the drawing officer and received with in the stipulated time.

Not Applicable

9 And whether the availment of No. of Instalments recorded (or) not Whether an entry is Made in the Service Register (or) not for previous claim

Not Applicable

10

Signature of the Government Servant

Signature of the Head of 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 1 Name, Designation & Section of Government Servant (in block letters) SRI. G.VENKATESWARLU SCHOOL ASSISTANT ZPHS KAVUR, 2 Office in which Employed Pay of the Government Servant as defined in F.Rs. and other employments which should be shown separately Place of Duty CHILAKALURIPET Mandal, Hyderabad District. 3 14860-39540 / 14860 ZPHS KAVUR, 4 CHILAKALURIPET Mandal, Hyderabad District. H.No. 16-1-178/A/9, 5 Full Residential Address with door number, name of the Mohalla and District Hari Puri Colony, Hyderabad. PIN - 500072 6 Name of the Patient, his/her relationship to the Government Servant, in case of children state age also Place at which the patient fell ill Baby. Y. Sarala, (Daughter) Aged 15 Years LALITHA SUPERSPECIALITY, GUNTUR

FEVER 8 Nature of illness and its duration From: 01-07-2009 From: From: Details of amount claimed, cost of Medicines purchased from the market/ list of Medicines purchased with cash memos, and the Essentiality Certificate should be attached each in duplicate signed To: To: To: 10-07-2009

List of Medicines in detailed and Essentiality Certificates are enclosed Rs. 20000=00 and Zero Only)

10 Total amount claimed

(Rupees Twenty Thousand Essentiality Certificate Emergency Certificate Discharge Summary Investigation Report Dependent Certificate Medical Bills Check List Non-Drawl Certificate

11 List of Enclosures

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 Government Servant

Signature of the Head 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. G.VENKATESWARLU, School Assistant, ZPHS KAVUR, CHILAKALURIPET Mandal, Hyderabad 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 Government Servant.

Signature of the Drawing & Disbursing Officer.

DESIGNATION 0 DISTRICT 1 Assistant Director 2 Assistant Engineer 3 Asst. Commissioner for Govt. Exams 4 Asst. Section Officer 5 Asst. Statistical Officer 6 Auditor 7 Cashier 8 Deputy Director 9 Deputy Educational Officer 10 Deputy Inspector of Schools 11 District B.C. Welfare Officer 12 District Educational Officer 13 District Tribal Welfare Officer 14 Divisional Engineer 15 Executive Engineer 16 Gazetted H.M. Gr-I 17 Gazetted H.M. Gr-II 18 Joint Director 19 Junior Assistant 20 Junior Lecturer 21 L.F.L. Head Master 22 L.F.L. Head Mistress 23 Language Pandit 24 Language Pandit (Hindi) 25 Language Pandit (Sanskrit) 26 Language Pandit (Tamil) SCALE OF PAY 27 Language Pandit (Telugu) 28 Language Pandit (Urdu) 29 Mandal Educational Officer 30 Office Subordinate 31 Physical Education Teacher 32 Principal 33 Project Officer 34 R.J.D.S.E. 35 Record Assistant 36 School Assistant 37 School Assistant (Bio. Sc.) 38 School Assistant (English) 39 School Assistant (Hindi) 40 School Assistant (Maths) 41 School Assistant (Phy. Edn.) 42 School Assistant (Phy. Science) 43 School Assistant (Soc. Stu.) 44 School Assistant (Telugu) 45 School Assistant (Urdu) 46 Secondary Grade Teacher 47 Senior Assistant 48 Senior Lecturer 49 Superintendent 0 0 0 0 0 0 0 0 0 0

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28

0 GENDER 0 0 Adilabad District 1 Male 1 Ananthapur District 2 Female 2 APSR Nellore District 0 0 0 Chittoor District OF RESIDENCE TYPE 0 HRA PERCENTAGE East Godavari District Govt. Quarters 1 1 Guntur District 2 Own House 2 Hyderabad District 3 Rented House 3 Kareemnagar District0 0 4 Khammam District 0 0 0 Krishna District MONTHS 0 C.C.A Kurnool District 1 Not Applicable 1 Mahboobnagar District 2 40247 2 Medak District 3 40278 3 Nalgonda District 4 40308 4 Nizamabad District 5 40339 5 Prakasham District 6 40369 0 Ranga Reddy District 7 40400 0 Sreekakulam District8 40431 SURRENDER CLAIMED DAYS Vishakapatnam District 9 40461 0 Vizianagaram District 10 40492 1 Warangal District 11 40522 2 West Godavari District 12 40553 3 YSR Kadapa District 13 40584 0 0 0 0 0 0 0 0 CPS 0 0 0 1 6700-20110 0 0 2 6900-20680 0 0 0 7100-21250 0 0 0 7520-22430 0 0 0 7740-23040 0 0 0 7960-23560 0 0 0 8440-24950 0 0 0 9200-27000 0 0 0 9460-27700 0 0 0 10020-29200 0 0 0 10900-31550 0 0 0 11530-33200 0 0 0 11860-34050 0 0 0 12550-35800 0 0 0 12910-36700 0 0 0 13660-38570 0 0 0 14860-39540 0 0 0 15280-40510 0 0 0 16150-42590 0 0 0 18030-43630 0 0 0 19050-45850 0 0 0 20680-46960 0 0 0 21820-48160 0 0 0 23650-49360 0 0 0 25600-50560 0 0 0 27000-51760 0 0 0 29200-53060 0 0 0 31550-53060 0 0 0

1 Father 2 Mother 3 self 4 Legal Hier 5 Husband 6 Wife 7 Son 8 Daughter 9 Widower 10 Nephew 11 Niece 0 DDO Desgn 1 Assistant Director 2 Deputy Director 3 Deputy Educational Officer 4 Deputy Inspector of Schools 5 Gazetted H.M. Gr-I 6 Gazetted H.M. Gr-II 7 Head Master 8 Head Mistress 9 Mandal Educational Officer 10 Principal 11 Project Officer 12 R.J.D.S.E. 0 0 0 0 0 0 Assistant Director 0 Deputy Director 0 Deputy Educational Officer 0 Deputy Inspector of Schools 0 Gazetted H.M. Gr-I 0 Gazetted H.M. Gr-II 0 Head Master 0 Head Mistress 0 Mandal Educational Officer 0 Principal 0 Project Officer 0 R.J.D.S.E. 0 0 0 1 Adilabad District 2 Ananthapur District 3 APSR Nellore District 4 Chittoor District 5 East Godavari District 6 Guntur District 7 Hyderabad District 8 Kareemnagar District 9 Khammam District 10 Krishna District

0 0

0 0 0 0 0

0 0 0 Adilabad Ananthapur Nellore Chittoor Kakinada Guntur Hyderabad Kareem Nagar Khammam Machilipatnam

29 30 31 32 0 1 2 3 0 1 2 3 4 5 6 7 0 0 1 2 0 0 0 0 0 0 0 0 0 0 2 2 1 1 2 2 2 2 1 2 1 1 0 0 0

34050-54360 37600-54360 41550-55660 44740-55660 0 Sri. Smt. Kum. 0 Baby. Kum. Master. Miss. Mrs. Smt. Sri. 0 0 Government Private 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 2 3 4 5 6 7 8 9 10 11 0 0 0 0 1 2 3 4 5 6 7 8 9 10 11 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Father Mother self Legal Hier Husband Wife Son Daughter Widower Nephew Niece 0 0 0 0 Father Mother self Legal Hier Husband Wife Son Daughter Widower Nephew Niece 0 0 0 he she he she he she he she she he she

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 his her his her his her his her her his her 0 0 0

11 12 13 14 15 16 17 18 19 20 21 22 23 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Kurnool District Mahboobnagar District Medak District Nalgonda District Nizamabad District Prakasham District Ranga Reddy District Sreekakulam District Vishakapatnam District Vizianagaram District Warangal District West Godavari District YSR Kadapa District 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Kurnool Mahboobnagar Sanga Reddy Nalgonda Nizamabad Ongole Hyderabad Sreekakulam Vishakapatnam Vizianagaram Warangal Elure Kadapa 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0

0 0 0 0 0 0 0

0 0 0 0 0 0 0

0 0 0 0 0 0 0

0 0 0 0 0 0 0

0 0 0 0 0 0 0

0 0 0 0 0 0 0

0 BASIC PAY Yes 1 No 2 0 3 0 4 10 5 12.5 6 20 7 30 8 0 9 0 10 Not Applicable 11 GHMC 12 GVMC 13 Vijayawada 14 Other MC 15 0 16 0 17 0 18 0 19 Not Applicable 20 15 21 30 22 0 23 0 24 0 25 Yes 26 No 27 0 28 0 29 0 30 0 31 0 32 0 33 0 34 0 35 0 36 0 37 0 38 0 39 0 40 0 41 0 42 0 43 0 44 0 45 0 46 0 47 0 48 0 49 0 50 0 51 0 52 0 53 0 54

0 6700 6900 7100 7300 7520 7740 7960 8200 8440 8680 8940 9200 9460 9740 10020 10300 10600 10900 11200 11530 11860 12190 12550 12910 13270 13660 14050 14440 14860 15280 15700 16150 16600 17050 17540 18030 18520 19050 19580 20110 20680 21250 21820 22430 23040 23650 24300 24950 25600 26300 27000 27700 28450 29200

0 LIST OF RECOGNISED HOSPITALS 0 0 0 0 0 0 1 A.P. Super Speciality0DentalRes Emp Hospital PVT Ltd, Road of the Employee 0 Name No. 2, Banjara H 0 2 Aditya Hospital, 4-1-16,Sri. 0 Boggulakunta, Tilak Road,G.VENKATESWAR G.VENKATESWARLU Hyderabad. Sri. Abids, 0 3 Alpha Hospital, 23-1-863, Near MCH Swimmingpool, Moghalpura, Hyd 0 0 0 0 0 4 Amaravathi Institute of Medical Science Pvt.0Ltd., Kothapet, Guntur 0 0 0 0 5 Ameerpet Superspeciality Dental Hospital &0 0 0 Implant Centre, 102 Class 0 0 6 American Institute of 0 Dentistry, Besides Chermas 8-3-944/12/4, Amee 0 0 Name of the Patient 0 7 Andhra Hospitals, CVRBaby. 0 Complex, Prakasam Road, Vijayawada Y. Sarala Baby. Y. Sarala 0 8 Ankith Multi Specialty Hospital, Ibrahim Patnam, R.R. Dist. 0 0 0 0 0 9 Apollo DRDO Hospital, Kanchanbagh, Secunderabad. 0 0 0 0 0 10 Apollo Hospital, Jublee Hills, Hyderabad 0 0 0 0 0 11 Apollo Hospital, Vikrampuri, Secunderabad. 0 Name of the DDO 0 0 0 12 Apollo Hospital, WaltairSri. 0 Mainroad, S. Gurunadha Rao VisakhapatnamS. Gurunadha Rao Sri. 0 13 Apollo Hospitals, D.No. 13-1-13,0 0 Main Road, Kakinada. 0 0 0 14 Aravind Kidney Centre,Sir 0 15/402, Brindavanam, Main Road, Nellore. 0 0 0 15 Aravind Nethralaya Meenakshi Diabetes and Endocrinology and Supe 0 0 0 0 0 16 ARK Hospital, Kukatpally, Hyderabad. 0 0 0 ENCLOSURES 0 17 Arun Kidney Center, 0 29-23-9, Tadepallivari Street, Suryaraopet, Vijaya 0 0 Essentiality Certificate 0 18 Asha Hospitals, Court Road, Anantapur. 0 0 0 Emergency Certificate 0 19 Asian Institute of Gastroenterology, Somajiguda, Hyderabad 0 0 0 Discharge Summary 0 20 Aswini Dental Hospital, 143-A Block, Aditya 0 InvestigationSaradhi Stu 0 0 Enclave, opp. Report 0 21 Aswini Hospital, Near RTC Bus Stand Mangalagiri Road, Guntur 0 0 0 Dependent Certificate 0 22 Baba Dental Clinic, 2nd Floor, Mediworld, 14-37-39, Maharanipet, Visa 0 0 0 Medical Bills 0 23 Bhimavaram Hospital, J.P. Road, Bhimavaram. 0 0 0 Checklist 0 24 Bollineni Eye Hospital and Research Center, Dargametta,Certificate 0 0 0 Non-Drawl Nellore. 0 25 Bollineni Heart Centre, 46-7-47, 0 0 Danavaipet, Rajhmundry. 0 SUM 0 26 Bollineni Ramanaiah 0 Memorial Hospital, Ambuja Centre, Durgamitta, N 0 0 0 0 27 Care Hospital (A unit0 Quality care India Ltd), Banjara 0 of 0 0 Hills, Hyderab 0 28 Care Hospital (Quality Care Inida Limited) Exhibition Road, Nampally, 0 0 0 0 0 29 Care Hospital, Waltair Main Road, Visakhapatnam 0 0 0 0 0 30 Chaitanya Dental Hospital, 1-1-230/33 Jyothi Bhavan, Chikkadpally, H 0 0 0 0 0 31 Challa Hospital, 7-1-71/A/1, Dharam Karan Road, Ameerpet, Hyderab 0 0 0 0 0 32 Charitasri Hospitals Ltd., 29-6-8/1, Ramachandra Rao Road, Suryarao 0 0 0 0 0 33 City Cardiac Research Center Ltd, Ring Road, Near ITI 0 0 0 0 College, Vijyaw 0 34 City Super Speciality 0 Dental Hospital, Shobha Pavani Complex, 1 st Fl 0 0 0 0 35 Dental Venue Multi Speciality Hospital, F-14, First Floor, Deepthi Apar 0 0 0 0 0 36 Diacon Diabetes Specialty Centre & Diagnostics, VV's Vintage Boulav 0 0 0 0 0 37 Dilsuknagar Superspeciality Dental Hospital, Sirigiri Complex, Dilsulkn 0 0 0 0 0 38 Dr. Gowds Dental Hospitals, #19, Durga Enclave, Road0No.12, Banjar 0 0 0 0 39 Dr. J.S.R. Dental Health Speciality, 1-128, Surya Towers, Bhavani Nag 0 0 0 0 0 40 Dr. Sridhar International Dental Hospital & Research Center, Eluru Ro 0 0 0 0 0 41 E.N.T. Nursing Home, Bhagathsingh Statu Center, Kothapet, Guntur 0 0 0 0 0 42 FMS Dental Hospital, Aiyangar Plaza, Bank 0 0 0 Street, Koti, Hyderbad 0 0 43 Frontier Lifeline (Pvt.0 Ltd.), Chennai 0 0 0 0 44 Geeta Mutli Speciality Hospital, 0 0 Seceunderabad. 0 0 0 45 Global Hospitals ( Aunit of Ravindranath GE0Medical Association Pvt. 0 0 0 0 46 Global Hospitals, Banjara Hills, Hyderabad 0 0 0 0 0 47 Global Meidcal Centre (A unit of 0 0 Andhra Helath Diagnositc Services Lt 0 0 0 48 Gowri Gopal Hospitals Pvt. Ltd., 0 0 Kurnool 0 0 0 49 GSL General Hospital, NH-5, Lakshmi Puram, Rajhmundry. 0 0 0 0 0 50 GVR Childrens Hospital, 43/48, 2nd Lane, N.R.Pet, Kurnool - 518004. 0 0 0 0 0 51 Harini Gastro & Liver0 Centre, 29-14-51, Prakasam Road, Suryaraopet 0 0 0 0 52 Health Hospitals Prakasam Road, Tenali - 522201,Guntur District. 0 0 0 0 0 53 Heart Care Centre, Dornakal Raod, Near Andhra Bank,0 0 0 0 Suryaraopet, V 0 54 Help Hospital, MG Road, Vijayawada 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 she 0 0 0 0 0 0 0 0 0 0 0 0 0 0 her 0 0 0 0 0 0 0 0 0 0 0 0 0

55 56 57 58 59 60 61 62 63 64 65 66 67 68 75 76 77 78 79 80 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

29950 30750 31550 32350 33200 34050 34900 35800 36700 37600 38570 39540 40510 41550 49360 50560 51760 53060 54360 55660 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109

Heritage Hospital, 6-3-907/2, Somajiguda, Hyderabad 0 0 0 0 Hope Childrens Hospital, 5-9-24/81, Lake Hills Road, Basheerbagh, H 0 0 0 0 Hyderabad Kidney & 0 Laproscopic Centre, Judges Colony,Malakpet, Hy 0 0 0 Image Hospital ( Image Health CareLimited)Ameerpet, Hyderabad 0 0 0 0 Indo- American Cancer Institute 0 Research Centre, Banjara Hills, Hyd 0 & 0 0 Jaya Hospitals, Chowrastha, Hanamkonda, 0 0 0 Warangal 0 Kalyani Dental Hospital Dentistry & Implant Centre, Opp. Green Park H 0 0 0 0 Kamineni Hospitals, L.B.Nagar, Hyderabad 0 0 0 0 Karumuri Hospitals, Old Club Road, Guntur 0 522001. 0 0 0 Kinnera Super Speciality Hospital, Wyra Road, Khammam 0 0 0 0 KNM Smile Dental Hospital, 104, Sai Towers, Beside Kalaniketan, Ma 0 0 0 0 Konaseema Institute 0 Medical Sciences, NH - 214, Chaitanya Nagar of 0 0 0 Krishna Children's Hospital, (A unit Ashwik Hospital Pvt0 0 0 0 Ltd), Niloufer H Krishna Institute of Medical Sceinces, Minister Road, Begumpet, Hyde 0 0 0 0 Kurnool Heart & Brain Centre, 43-1-1-K-B-4, Sapthagiri 0 0 0 0 Nagar, A-Cam L.K. Hospitals Pvt. Ltd., 4-159 & 0 0 4-172, Maruthi Nagar, Malkajgiri, Ran 0 0 Lalitha Superspeciality Hospital Heart & Brain Centre, Gowrisankar Th 0 0 0 0 Lazarus Hospital, Waltair main road, Visakhapatnam 0 0 0 0 Life Hospitals (a Unit0 Sai Balaji Health Care) Shivam 0 of 0 0 Road, D.D. Co Life Kare Dental Hospital, 9-7-83/1, Sri Laxmi Complex,0Maruthi Naga 0 0 0 Life Line Hospitals, 2-4-152, Ram Nagar, Hanmakonda, Warangal Dis 0 0 0 0 Lions District 324-C1, Cancer Treatment & Research Centre, Seetham 0 0 0 0 Lotus Children's Hospital, Lakdika Pool, Hyderabad. 0 0 0 0 M.S. Multi Speciality Dental Hospital, 8-2-165/8, Wyra Road, Khamma 0 0 0 0 Madhava Nursing Home, 43, Sarojini Devi Road, Secunderabad. 0 0 0 0 Mamatha General Hospital, 5-7-200, Giri Prasad Nagar, Urban Manda 0 0 0 0 Maxivision Laser Centre Pvt. Ltd., Begumpet, Hyderabad 0 0 0 0 Mediciti Hospital, 5-9-22, Secretariat Raod, Sarovar Complex, Hyderab 0 0 0 0 Medwin General Hospital, Mankamma Thota, Karimnagar. 0 0 0 0 Medwin Hospital, Chirag Ali Lane, Hyderabad 0 0 0 0 Meena Hospital, Sai Ranga Towers, Thukaram Gate, North Lallaguda 0 0 0 0 MNR Medical College & Hospital, Fasalwadi, Sangareddy, Medak Dist 0 0 0 0 Modern Eye Hospital, & Research Centre 16-11-101, Beside Venkatar 0 0 0 0 MVS Accident Hospital, Suryaraopet, Vijayawada 0 0 0 0 Mythri Multi Speciality Hospitals, 0 0 Ameerpet, 0 Hyderabad 0 N. N. Speciality Dental Hospital, 0 0 N.H. 7, Tirumala Theatre Road, Nirma 0 0 Nagarjuna Hospitals,Kanuru, Vijayawada-7 0 0 0 0 Narayana Medical College and Hospital, Chinta Reddy Palem, Nellore 0 0 0 0 Navata Multi Speciality Dental Care Center, 0 0 0 5-6-224, Saraswathi Naga 0 Naveen Dental Hospital, 151-A, Sri Ram Street, Tirupthi. 0 0 0 0 Navya Nethralaya 2-2-349, K.V. 0 0 Layout, (Near LIC Office) Tirupathi 0 0 New Life Hospital, Kamal Theatre Complex,0 0 0 Chaderghat, Hyderabad. 0 Nightingale Hospital, 0 17-1-383/N.S/3 & 4, Opp. Amber Biscult Factory, 0 0 0 NRI General Hospital, Chinakakani, Guntur 0 0 0 District. 0 Padma Chandra Super Specialty Hospital, Budhawarpet, Kurnool. 0 0 0 0 Partha Dental Hospital & Research Centre, 0 0 0 Rama Talkies Circle , Vis 0 Partha Dental Hospital & Research Centre, 600/44/77, P.K. Layout,Tir 0 0 0 0 Pinamaneni Care Hospital, Siddhartha Nagar, Vijayawada 0 0 0 0 Poulomi Hospital, Rukminipuri Colony, Dr. A.S. Rao Nagar, Main Road 0 0 0 0 Pragna Children's Hospital, 6-3-347/22/B/1, 0 0 0 Dwarkapuri0Colony, Near Premier Hospital, Masab tank, Humayun Nagar, Mehdipatnam, Hydera 0 0 0 0 Purna Heart Institute 0 Kovelamudivari Street,0Suryaraopet,Vijayawada 0 0 R.K. Super Speciality Dental Hospital, Andhra Bank Complex, Kothape 0 0 0 0 Rainbow Children Hospital,Banjara Hills, Hyderabad 0 0 0 0 Raju Neuro & Multispeciality Hospital,and Raju Emergency Hospital, 7 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 0 0 0 0 0

Ram Hospital, Shapur Nagar, IDA Jeedimetla, Hyderabad-500055 0 0 0 0 Ravi Institute of Child Health (RICH Hospitals) 16-11/131, Kasturidevi 0 0 0 0 Remedy Heart Institute (A unit of0Remedy Hospital Ltd.), Opp. TTD, H 0 0 0 Remedy Hospitals, Ferozguda, Balanagar, Hyderabad. 0 0 0 0 Remedy Hospitals, Road No.4, KPHB Colony Kukatpally, Hyderabad 0 0 0 0 Rohini Medicare (Pvt.) Limited, Subedari, Hanamkonda0 506 001, Wa 0 0 0 Royal Hospitals, 33-25-45, Kasturi Bai Pet, Vijayawada 0 0 0 0 Rukku's save-in-smile Cosmetic 0 0 and Dental 0 specilaity Hospital, Barkat 0 Sai Bhavani Super Specialty Hospital, Main 0 0 0 Road, Shapur Nagar, Jeed 0 Sai Care Hospital, Ambadkar Statue, Hanumakonda, Warangal 0 0 0 0 Sai Krishna Super Speciality Neuro & Trauma Hospital, 0 0 0 0 Kachiguda, Hy Sai Vani Hospital (A Unit of Lakshmi Jaya Hospitals Ltd., Opp. Indira P 0 0 0 0 Sai Venkata Sai Medical College& Hospital, 0 0 0 Yenugonda, Mahabubnag 0 Sanjana Palamoor Nursing Home, D.No. 8-6-257/7, Padmavathi Colon 0 0 0 0 Sankar Foundation Eye Hospital, D.No. 16-152, Srinivasa Nagar, Simh 0 0 0 0 Satya Kidney Centre,0Street No.4, Himayathnagar, Hyderabad. 0 0 0 Seven Hills Hospital, 0 Rockdale Layout, Visakhapatanam 0 0 0 Sharat Laser Eye Hospital, D.No. 3-1-119, Kakatiya Colony, Alankar C 0 0 0 0 Shravana Hospitals, 5-3-847, Mozamjahi Market, Hyderabad 0 0 0 0 Sibar Charitable Trust (Cancer Hospital), Governorpet,Vijayawada 0 0 0 0 Sigma Hospital, (A Unit of D.B.R0Hospital Pvt. Ltd.,35,S.D. Road, Secu 0 0 0 Siri Dental Clinic, Narayanaguda, Hyd. 0 0 0 0 Smiline Dental Hospital, Main Road, Ameerpet, Hyderabad 0 0 0 0 Smt. Bhagwan Devi Hospital, 21-7-191, Mama Jumla Pathak Charkam 0 0 0 0 Soumya Multi Speciality Hospital, Karkhana,0Secunderabad 0 0 0 Sri Devi Eye Hospital, 29-6-13A,0 0 Nakkal Road, Suryaraopet, Vijayawad 0 0 Sri Sai Hospitals, 5/2, Arundalpet, Guntur - 522002 0 0 0 0 Sri Sai Kidney Center, (A Unit of 0 0 Twin Cities0 Kidney Center Pvt Ltd.), 7 0 Sri Vijaya Durga Cardiac Centre 0 0 46-728-C, Budhawarpet, Kurnool 0 0 Sridhar Super Speciality Dental Hospital, Opp. Gold Spot, Ameerpet, H 0 0 0 0 St. Ann's Hospital, Fathimanagar, Kazipet, Warangal 0 0 0 0 SVR Neuro Hospital ( Aunit of SVR Neuro &0Trauma Super Speciality 0 0 0 SVS Dental Hospital,0Opp. Bata 0 R.P. Road, 0 Seceunderabad. 0 Swatantra Hospitals (Multi Specialities) Pvt. 0 0 0 Ltd. Near Kambala Park, R 0 Udai Clinic Orthopedic Center, Chappal Road, Hyderabad. 0 0 0 0 Usha Cardiac Centre, Labbipet, M.G.Road, 0 0 0 Vijayawada. 0 Usha Mullapudi Cardiac Centre, 0 0 Gajularamaram, Qutubullahpur Munic 0 0 Vamshi Multispciality0 Dental Hospital, 102-104, Ist Floor, Agraj Plaza, 0 0 0 Vasavi ENT & Cancer Institute, 6-1-91, Opp. Meera Theatre, Lakdikap 0 0 0 0 Vasvi Eye Hospital, 5-7-17, Khaleelwadi, Nizamabad. 0 0 0 0 Vijaya Eye Hospital, 5-8-104, Lakshimpuram, Guntur 0 0 0 0 Vijaya Health Care Centre,8-2- 86,Kumariguda, Near Passport office, 0 0 0 0 Vijaya Super Speciality Dental Hospital, opp. Rama Talkies, C.B.M. Co 0 0 0 0 Vijetha Hospital (A unit of Vijetha Helath Care and Research Centre P 0 0 0 0 Viswa Bharati Super 0 Speciality Hospital, Gayatri Estates, Kurnool 0 0 0 Wockhardt Hospitals, 4-1-1227, 0 0 King Koti Road, Abids, 0 0 Hyderabad 5 Woodlands Hospital,0 Barkatpura, Hyderabad 0 0 0 Yashoda Hospital, Secunderabad 0 0 0 0 Yashoda Suepr Speciality Hospital, Malakpet, Hyderabad 0 0 0 0 Yashoda Super Speciality Hospital, Somajiguda, Hyderabad 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

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0 0 0 0 0 0 0

0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 DesignationPlace of working Mandal District Scale of Pay asic Pay Add1 B Add2 Add3 Add4 School Assistant KAVUR ZPHS CHILAKALURIPET Mandal Hyderabad 14860-39540 14860 H.No. 16-1-178/A/9 Colony District Hari Puri Hyderabad PIN - 500072 0 0 0 Hyderabad 14860-39540 / 14860 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Relationship with Emp Name of the Hospitalthe TreatmentAmount in Words Joining of Discharge submission of Proposal to D Age of Patient Name of Amount in Figures Date of Date Date of 0 Daughter 15 Years LALITHA SUPERSPECIALITY, GUNTUR Twenty Thousand and Zero Only) Fever 20000 (Rupees 39995 40004 40047 0 0 15 Category of Hospital 0 0 0 0 0 0 0 0 0 Private 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 DesignationPlace of working Mandal District 0 0 he 0 0 0 Head Master Govt. High School, Begum Bazar District 0 Khairthabad Mandal Hyderabad 0 his him 20000=00 from 01-07-2009 to 10-0 2 0 1 0 0 With reference to the subject cited, I submit herewith the Me 0 0 0 0 The Head Master, The Head Master, The DistrictThe Commissioner Govt. High of0 Educational Officer, 0Director School, BegumHyderabad District,District. Khairthabad Mandal Khairthabad Mandal, & 0 Bazar,Hyderabad 0 0 School Education, Andhra Prades 0 Hyd 0 0 0 0 0 20000=00(Rupees (Rupees Twenty Thousand and Zero Only) only 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 Essentiality Certificate 0 0 0 0 0 0 0 2 Emergency Certificate 0 0 With reference to the subject cited, I submit herewith the Me 0 0 0 0 2 Discharge Summary 0 0 0 0 0 0 0 2 Investigation Report 0 0 0 0 0 0 0 2 Dependent Certificate 0 0 0 0 0 0 0 2 Medical Bills 0 0 0 0 0 0 0 2 Check List 0 0 0 0 0 0 0 2 Non-Drawl Certificate 0 0 0 0 0 0 0 16 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 DEPENDENT CERTIFICATE 0 0 0 0 0 0 0 0 0 I, SRI. G.VENKATESWARLU, School Assistant, ZPHS KA 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

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PIN - 500072

from 01-07-2009 to 10-07-2009