Contact phone No’s, Res.

: 8121959586
Office : 9440817030
FORM OF APPLICATION FOR MEDICAL CLAIMS
(for In –Patient Treatment)

1. Name of the Employee : K. DASARADHA CHARI

2. Date of Birth : 13-06-1970
3. Desiganation and Basic pay : Dy.EX.Engineer/Electrical/Shift
4. Section and office in which employed :400kv substation, chittoor
5. Employee. I.D.No/PPO.NO.if Retrired :I.D.NO- 1049870
6. Place of retirement(pensioners) : ---------
7. Present office address : 400kv substation, chittoor
8. Actual Residential Address : plot no 11 , Sri chakra nagar layout, Thondawada,
Thirupathi(Dist)
9. Office and place where wife/Husband
Is Employed (if both are employed) : un employed (house wife)
10. Name of the patient and relationship
(in case of children stage age also with
Age proof) : K. RAJANI(Wife 45 years)
11. Name of the medical attendant and
Address and name of the Hospital : SVIMS, TIRUPATHI
12. Name of the disease in block letters : Type 1 respiratory failure(Interstitial lung disease )
13. Peiod of treatment as in patient
In –patient / indicated in the certificate : 01-07-2022 to 13-02-2022(13 days)
14. Details of medical charges incurred
Medical attendance(include
hospital treatment) : As per medical bill –ESSENTIALITY CERTIFICATE
a) The No. and Dates of consultation
And fees paid for each consultation : one, Rs 1000-00 (01-07-2022)+9400-00=10,400-00
b) The No. and Dates of Injections
and fees paid for each injection : Rs 11,185-00
c) Details of laborites tests (X-Ray
Charges , scanning etc : Rs 36,520-00
d) Cost of medicine (details of the
Consolidated medicines shall be
Furnished in the essentiality
Certificate : Rs 14,118-53
15. Hospital treatment
a) Accommodation charges& bed
Charges : Rs 10,600-00
b) Diet charges : Nil
 c) Lab charges(details shall be
Furnished including general
Stores & surgical stores including
Miscellaneous charges : Rs 12,322-47
d) Surgeons fee : Nil
e) Asst. surgeon’s fee : Nil
f) Anesthetist fee : Nil
g) Theatre charges(Emergency
Medicine) : Rs 25,780-00
h) Nursing charges :
i) Blood charges :
16. Total amount claimed : Rs 1,20,926-00
17. Less advance taken on : Nil
18. Net amount claimed : Rs 1,20,926-00 ( Rupees. One lakh twenty thousand
nine hundred and twenty six only)
19. No. of enclosures. : Nos

Declaration to be signed by the Employee

I here by declare that the statement furnished above are true to the best of my knowledge
and belief and person for whom the above medical expenses were incurred is wholly dependent on me.

(SIGNATURE OF THE EMPLOYEE)

(K.DASARADHACHARI, Dy.EE/Ele/S/400 KV SS/CTR)

Countersigned Recommended/ submitted to : Superintending Engineer/4 00KV/O&M/KADAPA for

taking necessary action please.

(SIGNATURE OF THE CONTROLLING OFFICER)

(With date, designation and stamp)

Note:- The claim shall be supported by Essentiality certificate and cash receipts of the expenses shall be countersigned by
doctor /medical officer.
All the cash receipts shall be within the period of treatment as indicated in the essentiality certificate. They must necessarily
contain the name of the patient ,name of doctor and date of issue.
The claim of the employee other than thoseopted for treatment at the dispensary of vidyut soudha shall be only for chronic
diseases like T.B or other major operations and the same shall be indicated by the doctor in the essentiality certificate.
All the medical bills shall be submitted to their controlling officers within 3 months from the last date of the treatment
period/from the date of the bill who in turn ofter scrutiny,forwarded to the sanctioning authority as per powers delegated in
B.P.Ms.NO.238, dt.13-12-1995 so as to enable this office to sanction the amount immediatlely.
 DECLARATION(DEPENDENCY) CERTIFICATE

I, K.Dasaradhachari, Dy. Executive Engineer/Shift/400 KV SS/Chittoor here

by declare that my Wife Smt. Kodakanti . Rajani has no property or income of his / her
own and that he / she is wholly dependent upon me

Station: Chittoor Signature & Designation

Date :

CERTIFICATE ‘B’

(To be completed in the case of patients who are admitted in the Hospital for treatment)

Certificate granted to Mrs, Mr./Miss ______________________________________

Wife / Son / daughter of Mrs. / Mr. ______________________________________

Employed in the _________________________________________________________

 CERTIFICATE ‘B’

(To be completed in the case of patients who are admitted in the Hospital for treatment)

Certificate granted to Mrs, Mr./Miss ______________________________________

Wife / Son / daughter of Mrs. / Mr. ______________________________________

Employed in the _________________________________________________________