MEDICAL REIUMBURSEMENT FOR STATE GOVERNMENT EMPLOYEES

PERSONAL DETAILS DOCUMENTS TO BE ENCLOSED

Name of the Employee Sri. 1 Y. Ramana Rao Please select the documents that are enclosed with Bill
Designation 40 Assistant (Maths)
School ✘ 1
Essentiality Certificate

Place of Working Govt. High School, Begum Bazar ✘ 1

Emergency Certificate

Name of the Mandal Khairthabad ✘ 1

Discharge Summary

Name of the District 7

Hyderabad District ✘ 1
Investigation Report.

Present Scale of Pay 17

14860-39540 ✘ 1
Dependent Certificate

Present Basic Pay 29

14860 ✘ 1
Medicine Bills

H.No. 16-1-178/A/9 ✘ 1 List.

Check

Hari Puri Colony ✘ 1

Non-Drawl Certificate
Residential Address
Hyderabad
PIN CODE 500072

PATIENT DETAILS
Name of the Patient 1
Baby. Y. Sarala CLICK ON THE FOLLOWING LINKS
Relationship with Employee 8
Daughter Letter to the D.D.O.
Age of the Patient 15 Years Letter to the Higher Authorities
Name of the Hospital LALITHA SUPERSPECIALITY, GUNTU Non-Drawl Certificate
Category of the Hospital 2
Private Check List for sending Proposals.
Name of the Treatment Fever Appendix - II
Amount of Hospital Bill in figures (Rs.) 15462 Dependent Certificate.
Date of Joing in the Hospital DD-MM-YYYY 01-07-2009 Note: To unprotect the sheets from 1 to 6 password: TEACHER
Date of Discharge DD-MM-YYYY 10-07-2009
Date of submission of Proposals to DDO DD-MM-YYYY 22-08-2009
Developed By:
K. Sreenivas Reddy working on deputation at O/o the
D.D.O. DETAILS District Educational Officer, Hyderabad District.
Name of the D.D.O Sri. 1 S. Gurunadha Rao
Please verify with experts before submission.
Designation Head Master 7
D.D.O. Place of Working Govt. High School, Begum Bazar For your valuable suggestion please contact
D.D.O. Mandal Khairthabad Ph.No. 9848363735 (or) [email protected]

D.D.O. District 7
Hyderabad District
 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 repect of SRI. Y. RAMANA

RAO, School Assistant (Maths), Govt. High School, Begum Bazar, Khairthabad
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.

-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 LALITHA SUPERSPECIALITY, GUNTU 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 Govt. High School, Begum Bazar,
Discharge Summary Khairthabad Mandal,
Investigation Report Hyderabad District.
Dependent Certificate
Medical Bills
Check List
Non-Drawl Certificate
 GOVERNMENT OF ANDHRA PRADESH
DEPARTMENT OF SCHOOL EDUCATION

From To
The Head Master, The District Educational Officer,
Govt. High School, Begum Bazar, Hyderabad District,
Khairthabad Mandal, Hyderabad.
Hyderabad District.

Lr. No. __________, Dt: __________ .

Respected Madam,

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

RAMANA RAO, School Assistant (Maths), Govt. High School, Begum Bazar,
Khairthabad 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 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), Govt. High

School, Begum Bazar, Khairthabad Mandal, Hyderabad 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 LALITHA

SUPERSPECIALITY, GUNTU 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
 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), Govt. High School, Begum Bazar, Khairthabad 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, GUNTU 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.
 SPECIMEN CHEK LIST

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

SRI. Y. RAMANA RAO

School Assistant (Maths)
Govt. High School, Begum Bazar,
1 Name and Address of the employee Employee code
Khairthabad Mandal,
Hyderabad District.

If Retired
a)Date/Year of Retirement

2 b)Designation
c) P.P.O.NO

School Assistant (Maths)

Govt. High School, Begum Bazar,
Khairthabad Mandal,
3 Communication of the Applicant Address For all purposes with cell no.
Hyderabad District.

cell no.

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

Name and Address of Hospital LALITHA SUPERSPECIALITY, GUNTU

5
a)Whether Private Hospital (or) Recognized Hospital RECOGNISED

b)Whether referral Letter Produced (or) Recognized orders to be

YES / NO
enclosed along with the proposals

Whether the Medical Reimbursement Proposal sent with in 6 Months from

6 YES / NO
the Date of Discharge

Whether the Following are Enclosed

1)Appendix-II duly attested by the Head of the office/DDO YES / NO

2)Emergency Certificate YES / NO

3)DischargeSummary
YES / NO
4)

5) Non drawl Cerficate YES / NO

6)Essentially certificate, attested by the authorized doctor, who

YES / NO
7 undertakes treatment

7)If the Patient is dependent on the Govt.Employee-Un Employee crfificate

and dependency certificate are to be enclosed with the Medical Not Applicable
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. 15-03-2005 and
G.O.Ms.No.60 HM &(K1) Dept.Dt 09-04-2007 and also G.O. Ms No 180
dt.11-05-2006.

Whether the medical Reimbursement claim is processed throught the

8
drawing officer and received with in the stipulated time.

9 And whether the availment of No. of Instalments recorded (or) not Not Applicable

Whether an entry is Made in the Service Register (or) not for previous
10
claim
 Signature of the Signature of the
Government Servant 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

Name, Designation & Section of Government Servant SRI. Y. RAMANA RAO

1
(in block letters) SCHOOL ASSISTANT (MATHS)
Govt. High School, Begum Bazar,
2 Office in which Employed Khairthabad Mandal,
Hyderabad District.
Pay of the Government Servant as defined in F.Rs.
3 and other employments which should be shown 14860-39540 / 14860
separately
Govt. High School, Begum Bazar,
4 Place of Duty Khairthabad Mandal,
Hyderabad District.
H.No. 16-1-178/A/9,

Full Residential Address with door number, name of Hari Puri Colony,
5
the Mohalla and District Hyderabad.
PIN - 500072

Name of the Patient, his/her relationship to the Baby. Y. Sarala, (Daughter)

6 Government Servant, in case of children state age
also Aged 15 Years

7 Place at which the patient fell ill LALITHA SUPERSPECIALITY, GUNTU

FEVER
8 Nature of illness and its duration

From: 01-07-2009 To: 10-07-2009

Details of amount claimed, cost of Medicines
List of Medicines in detailed
purchased from the market/ list of Medicines
9 purchased with cash memos, and the Essentiality and
Certificate should be attached each in duplicate
Essentiality Certificates are enclosed
signed
Rs. 15462=00

10 Total amount claimed (Rupees Fifteen Thousand Four Hundred and

Sixty Two Only)

Essentiality Certificate
Emergency Certificate
Discharge Summary
Investigation Report
11 List of Enclosures
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
 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), Govt. High

School, Begum Bazar, Khairthabad 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 Signature of the

Government Servant. Drawing & Disbursing Officer.