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
Sri. 1

DOCUMENTS TO BE ENCLOSED
KARRI.SURYA NARYANA 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 TRUE List. Non-Drawl Certificate TRUE

School Assistant (Maths) 40

Govt.T.W.A.H.School,K.G.Pudi Vepada
Vizianagaram District 20 18030-43630 20 28450 53

D.No:16-272/12,flat no:D,3rd floor, Residential Address Mangipudi residency,Prahladapuram Vishakhapatnam PIN CODE 530027

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
Smt. 6 Mother 2

KARRI.NARAYANAMMA

CLICK ON THE FOLLOWING LINKS

Letter to the D.D.O. 70 Years Letter to the Higher Authorities Sankar Foundation Eye Hospital, D.No. 16-152, Srinivasa Nagar, Simhachalam Road, Visakhapatnam - 530027. 124 Non-Drawl Certificate Private 2 Check List for sending Proposals. CATTERACT SURGERY FOR RIGHT Appendix - II EYE 5500 Dependent Certificate.
DD-MM-YYYY DD-MM-YYYY DD-MM-YYYY 16-12-2011 17-12-2011 -01-2012
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 1 Sri. D.Maruthipatnaik 7
Head Master

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

Govt.T.W.A.H.School,K.G.PUDI VEPADA
Vizianagaram District 20

Date: To The Head Master, Govt.T.W.A.H.School,K.G.PUDI, VEPADA Mandal, Vizianagaram District.

-01-2012

Sir, Sub: Request to sanction the Medical Reimbursement in repect of SRI. KARRI.SURYA NARYANA, School Assistant (Maths), Govt.T.W.A.H.School,K.G.Pudi, Vepada Mandal, Vizianagaram 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. -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. 5500=00 (Rupees (Rupees Five Thousand Five Hundred and Zero Only) only) as my Mother named SMT. KARRI.NARAYANAMMA who is wholly dependent on me has undergone Treatment for the desease CATTERACT SURGERY FOR RIGHT EYE in the Recognised Hospital by the Andhra Pradesh State Government i.e., at SANKAR FOUNDATION EYE HOSPITAL, D.NO. 16-152, SRINIVASA NAGAR, SIMHACHALAM ROAD, VISAKHAPATNAM - 530027. during the period from 16-12-2011 to 17-12-2011 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 (KARRI.SURYA NARYANA) School Assistant (Maths), Govt.T.W.A.H.School,K.G.Pudi, Vepada Mandal, Vizianagaram District.

GOVERNMENT OF ANDHRA PRADESH TRIBAL WELFARE DEPARTMENT(EDUCATION). From The Head Master, Govt.T.W.A.H.School,K.G.PUDI, VEPADA Mandal, Vizianagaram District. Lr. No. __________, Dt: _ Respected Madam, Sub: Request to sanction the Medical Reimbursement in respect of SRI. KARRI.SURYA NARYANA, School Assistant (Maths), Govt.T.W.A.H.School,K.G.Pudi, Vepada Mandal, Vizianagaram District Proposals submitted - Reg. Ref: 1. 2. 3. 4. G.O. Ms.No. 74, M&H Dept., dated: 15-03-2005. G.O.Ms.No. 105, M&H Dept., dated: 09-04-2007. Medical Bills issued by the Doctor concerned. Proposals received from the incumbent dated: -01-2012 -o0oWith reference to the subject cited, I submit herewith the Medical Bills with all the enclosures submitted by SRI. KARRI.SURYA NARYANA, School Assistant (Maths), Govt.T.W.A.H.School,K.G.Pudi, Vepada Mandal, Vizianagaram District for your kind sanction of the Medical Reimbursement for an amount of Rs. 5500=00(Rupees (Rupees Five Thousand Five Hundred and Zero Only) only) as his Mother SMT. KARRI.NARAYANAMMA who is wholly dependent on him has undergone Treatment for desease CATTERACT SURGERY FOR RIGHT EYE in the Recognised Hospital by the Andhra Pradesh State Government i.e., at SANKAR FOUNDATION EYE HOSPITAL, D.NO. 16-152, SRINIVASA NAGAR, SIMHACHALAM ROAD, VISAKHAPATNAM - 530027. during the period from 16-12-2011 to 17-12-2011 and onward transmit to the higher authorities for further necessary ction at an early date. To The Deputy.Director(T.W), Tribal Welfare Dept. Parvathipuram. /01/2012___ .

Thanking You sir. Enclosures: Essentiality Certificate Emergency Certificate Discharge Summary Investigation Report Dependent Certificate Medical Bills Check List Non-Drawl Certificate

Yours faithfully,

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. 5500=00 (Rupees (Rupees Five Thousand Five Hundred and Zero Only) only) is being claimed now in this bill by SRI. KARRI.SURYA NARYANA, School Assistant (Maths), Govt.T.W.A.H.School,K.G.Pudi, Vepada Mandal, Vizianagaram District has not been paid previusly towards Medical Reimbursement in respect of his Mother named SMT. KARRI.NARAYANAMMA age (70) Years who has undergone the Treatment for the desease CATTERACT SURGERY FOR RIGHT EYE during the period from 16-12-2011 to 17-12-2011 in the Recongised Hospital by the Andhra Pradesh State Government i.e., at SANKAR FOUNDATION EYE HOSPITAL, D.NO. 16-152, SRINIVASA NAGAR, SIMHACHALAM ROAD, VISAKHAPATNAM - 530027. 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 Government Servant.

Signature of the Drawing & Disbursing Officer.

CHECK SLIP FOR SENDING MEDICAL REIMBURSEMENT PROPOSALS SRI. KARRI.SURYA NARYANA School Assistant (Maths) 1 Name and Official Address of the Teacher Govt.T.W.A.H.School,K.G.Pudi, Vepada Mandal, Vizianagaram District. 2 Dates of Treatment From: 16-12-2011 To: 17-12-2011

3 Name and Address of Hospital

SANKAR FOUNDATION EYE HOSPITAL, D.NO. 16152, SRINIVASA NAGAR, SIMHACHALAM ROAD, VISAKHAPATNAM - 530027. PRIVATE

4 Whether Private or Government? Whether the proposal is received in the Head 5 Office within a period of six months from the date of discharge? 6 Whether Appendix II attested by the Head of the Office is enclosed?

YES / NO

YES / NO

In case of Treatment at Recognized Hospital / 7 NIMS / SVIMS whether Emergency Certificate enclosed? Whether Essentiality Certificate mentioning the amount of expenditure for the Treatment 8 signed by the Doctor who treated and attested by the Authorized Medical Agency is enclosed? Whether the bills for the amount mentioned 9 in the Essentiality Certificate attested by the Doctor who treated /A.M.A. are enclosed? 10 Whether the Discharge Patient enclosed? Summary of the

YES / NO

YES / NO

YES / NO

YES / NO

11

In case of retired teachers whether the copy of the Pension Payment Order is enclosed?

Not Applicable

In case of dependents above the age of 18 years, unemployment and Dependency 12 Certificate counter signed by the Head of the Office is enclosed?

YES

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. KARRI.SURYA NARYANA SCHOOL ASSISTANT (MATHS) Govt.T.W.A.H.School,K.G.Pudi, 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 Vepada Mandal, Vizianagaram District. 3 18030-43630 / 28450 Govt.T.W.A.H.School,K.G.Pudi, 4 Vepada Mandal, Vizianagaram District. D.No:16-272/12,flat no:D,3rd floor,, 5 Full Residential Address with door number, name of the Mohalla and District Mangipudi residency,Prahladapuram, Vishakhapatnam. PIN - 530027 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 Smt. KARRI.NARAYANAMMA, (Mother) Aged 70 Years Sankar Foundation Eye Hospital, D.No. 16-152, Srinivasa Nagar, Simhachalam Road, Visakhapatnam - 530027. CATTERACT SURGERY FOR RIGHT EYE From: 16-12-2011 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: 17-12-2011

Nature of illness and its duration

List of Medicines in detailed and Essentiality Certificates are enclosed Rs. 5500=00 Five Thousand Five Hundred and Zero

10 Total amount claimed

(Rupees Only)

Essentiality Certificate Emergency Certificate Discharge Summary 11 List of Enclosures 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 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. KARRI.SURYA NARYANA, School Assistant (Maths), Govt.T.W.A.H.School,K.G.Pudi, Vepada Mandal, Vizianagaram District, do hereby declare that, SMT. KARRI.NARAYANAMMA, age (70) Years is my Mother 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.