MEDICAL REIUMBURSEMENT FOR STATE GOVERNMENT EMPLOYEES

PERSONAL DETAILS DOCUMENTS TO BE ENCLOSED

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

Place of Working ZPP. High School, Balayapalli ✘TRUE

Emergency Certificate

Name of the Mandal Balayapalli ✘TRUE

Discharge Summary

Name of the District 3 Nellore District

APSR ✘TRUE
Investigation Report.

Present Scale of Pay 17

14860-39540 ✘TRUE
Dependent Certificate

Present Basic Pay 29

14860 ✘TRUE
Medicine Bills

H.No. 7-197 ✘TRUE

Check List.

PS Street ✘TRUE
Non-Drawl Certificate
Residential Address
Venkatagiri
PIN CODE 524132

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 159 Super Speciality Hospital, Somajiguda, Hyderabad
Yashoda 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 P.Subbarayudu
Please verify with experts before submission.
Designation Head Master 7
D.D.O. Place of Working ZPP High School, Balayapalli For your valuable suggestion please contact
D.D.O. Mandal Balayapalli Ph.No. 9848363735 (or) ksr_0708@yahoo.co.in

D.D.O. District 7
Hyderabad District
 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.

G.BHASKERREDDY, 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: (G.BHASKERREDDY)
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
 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.

G.BHASKERREDDY, 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. G.BHASKERREDDY, 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
 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. G.BHASKERREDDY, 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.
 CHECK SLIP FOR SENDING MEDICAL REIMBURSEMENT PROPOSALS

SRI. G.BHASKERREDDY

School Assistant (Maths)

1 Name and Official Address of the Teacher 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
 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. G.BHASKERREDDY

1
(in block letters) SCHOOL ASSISTANT (MATHS)
ZPP. High School, Balayapalli,
2 Office in which Employed 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
ZPP. High School, Balayapalli,
4 Place of Duty Balayapalli Mandal,
APSR Nellore District.
H.No. 7-197,

Full Residential Address with door number, name of PS Street,

5
the Mohalla and District Venkatagiri.
PIN - 524132

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

Yashoda Super Speciality Hospital, Somajiguda,

7 Place at which the patient fell ill
Hyderabad

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. G.BHASKERREDDY, 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.