This action might not be possible to undo. Are you sure you want to continue?
Name of the Employee Designation Place of Working Name of the Mandal Name of the District Present Scale of Pay Present Basic Pay
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
þÿSchool Assistant (Maths) 40
þÿVizianagaram District 20 þÿ18030-43630 20 þÿ28450 53
D.No:16-272/12,flat no:D,3rd floor, Residential Address Mangipudi residency,Prahladapuram Vishakhapatnam PIN CODE 530027
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
þÿSmt. 6 þÿMother 2
CLICK ON THE FOLLOWING LINKS
Letter to the D.D.O. 70 Years Letter to the Higher Authorities þÿSankar Foundation Eye Hospital, D.No. 16-152, Srinivasa Nagar, Simhachalam Road, Visakhapatnam - 530027. 124 Non-Drawl Certificate þÿPrivate 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
K. Sreenivas Reddy working on deputation at O/o the District Educational Officer, Hyderabad District.
Name of the D.D.O Designation D.D.O. Place of Working D.D.O. Mandal D.D.O. District 1 þÿSri. D.Maruthipatnaik 7
Please verify with experts before submission. For your valuable suggestion please contact Ph.No. 9848363735 (or) email@example.com
þÿVizianagaram District 20
Medical Bills issued by the Doctor concerned.O. 2..W.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. -o0oWith reference to the subject cited.A. VEPADA Mandal.Reg.T.G. G. Ref: 1. . Vizianagaram District. Enclosures: Essentiality Certificate Emergency Certificate Discharge Summary Investigation Report Dependent Certificate Medical Bills Check List Non-Drawl Certificate (KARRI.G.SURYA NARYANA) School Assistant (Maths).e.Pudi. 105. Yours faithfully. KARRI. dated: 15-03-2005.T..530027.W.K.K.School. 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. Vizianagaram District. D. Sub: Request to sanction the Medical Reimbursement in repect of SRI. Govt.K.Pudi.G. Govt.PUDI.No.School.NO. Ms. dated: 09-04-2007.O.W. G. Govt.H. SRINIVASA NAGAR.SURYA NARYANA.School.T. 74. School Assistant (Maths). at SANKAR FOUNDATION EYE HOSPITAL.A. SIMHACHALAM ROAD. 3. 5500=00 (Rupees (Rupees Five Thousand Five Hundred and Zero Only) only) as my Mother named SMT.No. -01-2012 Sir.H.H. KARRI. Vepada Mandal.Date: To The Head Master. M&H Dept. Thanking You Sir. Vizianagaram District Proposals submitted .A. VISAKHAPATNAM . I submit here with the Medical Bills with all the enclosures for Medical Reimbursement for an amount of Rs. M&H Dept. Vepada Mandal. 16-152.. Ms.
4.No.A.Ms. Govt. dated: 15-03-2005.. Sub: Request to sanction the Medical Reimbursement in respect of SRI. 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. 2. Dt: _ Respected Madam.W). SIMHACHALAM ROAD. D.H.W. I submit herewith the Medical Bills with all the enclosures submitted by SRI. G.School.T.e. Lr. Thanking You sir.SURYA NARYANA. KARRI.O.K.530027. Vizianagaram District.H.A. VEPADA Mandal. 105.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..W. KARRI. 74.W. Tribal Welfare Dept.Director(T.T. 16-152.Pudi. KARRI. School Assistant (Maths). .A.School. Vizianagaram District for your kind sanction of the Medical Reimbursement for an amount of Rs. M&H Dept. SRINIVASA NAGAR. Proposals received from the incumbent dated: -01-2012 -o0oWith reference to the subject cited.. Ref: 1.G. Vepada Mandal. Ms.K.PUDI.No. at SANKAR FOUNDATION EYE HOSPITAL. Vizianagaram District Proposals submitted .School.T.H. From The Head Master. G. VISAKHAPATNAM . No. Enclosures: Essentiality Certificate Emergency Certificate Discharge Summary Investigation Report Dependent Certificate Medical Bills Check List Non-Drawl Certificate Yours faithfully. To The Deputy. Vepada Mandal. __________. M&H Dept. Medical Bills issued by the Doctor concerned. 5500=00(Rupees (Rupees Five Thousand Five Hundred and Zero Only) only) as his Mother SMT. Parvathipuram. Govt.SURYA NARYANA.Pudi. /01/2012___ .NO.K.GOVERNMENT OF ANDHRA PRADESH TRIBAL WELFARE DEPARTMENT(EDUCATION). School Assistant (Maths). Govt.Reg.G.O. dated: 09-04-2007. 3.G.
e.T.530027. Rc.K.SURYA NARYANA. Signature of the Drawing & Disbursing Officer.A. as per the records available regarding the Medical Reimbursement defined under the Government Medical Attendance Rules..Pudi. D.G.NON DRAWL CERTIFICATE (As per instructions issued in C & DSE.. Vizianagaram District has not been paid previusly towards Medical Reimbursement in respect of his Mother named SMT. VISAKHAPATNAM .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. SRINIVASA NAGAR. A. SIMHACHALAM ROAD.H.P. Vepada Mandal. 5500=00 (Rupees (Rupees Five Thousand Five Hundred and Zero Only) only) is being claimed now in this bill by SRI.NO. 16-152.School. dated: 02-09-2009) This is to certify that. at SANKAR FOUNDATION EYE HOSPITAL. . Hyderabad Procs. 1972 A note to that effect has also been made in the records of the school. KARRI. Signature of the Government Servant. the amount of Rs. KARRI. 8878/D3-4/2009.No.W. School Assistant (Maths). Govt.
2 Dates of Treatment From: 16-12-2011 To: 17-12-2011 3 Name and Address of Hospital SANKAR FOUNDATION EYE HOSPITAL.530027. KARRI.M. D. VISAKHAPATNAM . 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. SRINIVASA NAGAR.G.H. 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 .W. Vizianagaram District. Vepada Mandal.K. 16152.School.NO.A.Pudi.CHECK SLIP FOR SENDING MEDICAL REIMBURSEMENT PROPOSALS SRI. 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.T.SURYA NARYANA School Assistant (Maths) 1 Name and Official Address of the Teacher Govt.A. SIMHACHALAM ROAD.
NARAYANAMMA. Designation & Section of Government Servant (in block letters) SRI. 2 Office in which Employed Pay of the Government Servant as defined in F.W.A. Vizianagaram District.No:16-272/12. 4 Vepada Mandal. CATTERACT SURGERY FOR RIGHT EYE From: 16-12-2011 Details of amount claimed.H. his/her relationship to the Government Servant. Vizianagaram District. Servant Medical Attendance Rules and wholly dependent upon me. and the Essentiality Certificate should be attached each in duplicate signed To: 17-12-2011 7 8 Nature of illness and its duration List of Medicines in detailed and Essentiality Certificates are enclosed Rs. KARRI.flat no:D. name of the Mohalla and District Mangipudi residency. D. in case of children state age also Place at which the patient fell ill Smt. Visakhapatnam . Simhachalam Road.G.G.T.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.Pudi.Rs.T.K.Pudi. Signature of the Government Servant Signature of the Head of the Office .School.Prahladapuram.W. 16-152. 5 Full Residential Address with door number. Srinivasa Nagar.3rd floor.530027.No. KARRI.A.530027 6 Name of the Patient.. PIN . and other employments which should be shown separately Place of Duty Vepada Mandal. 5500=00 Five Thousand Five Hundred and Zero 9 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.School. Vishakhapatnam.SURYA NARYANA SCHOOL ASSISTANT (MATHS) Govt. 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. (Mother) Aged 70 Years Sankar Foundation Eye Hospital.H. cost of Medicines purchased from the market/ list of Medicines purchased with cash memos.K. 3 18030-43630 / 28450 Govt. D.
No. dated: 02-09-2009) I.School.G. Signature of the Drawing & Disbursing Officer.K.SURYA NARYANA.NARAYANAMMA.H. Rc. A. KARRI. age (70) Years is my Mother and has no property of income of her own and that. Vizianagaram District. School Assistant (Maths). KARRI.DEPENDENT CERTIFICATE GIVEN BY THE GOVERNMENT SERVANT (As per instructions issued in C & DSE. . 8878/D3-4/2009. Hyderabad Procs.P.Pudi. SMT. she is also not a Employee or Pensioner Signature of the Government Servant.. she is wholly dependent on me only. SRI.T.A. Govt. Vepada Mandal.W. do hereby declare that.
This action might not be possible to undo. Are you sure you want to continue?
We've moved you to where you read on your other device.
Get the full title to continue reading from where you left off, or restart the preview.