PREPARED BY

Name: G.RAVINDER GOUD Designation: SA(MATHS) Working Place MPUPS RAVULA PALLY Dist: RANGA REDDY Ph.No. 9491675215
NAME OF PATIENT G.PADMA LATHA RELATIONSHIP WITH THE EMPLOYEE WIFE NAME OF EMPLOYEE DESINATION OFFICE OF WORK MANDAL DISTRICT SCALE&PAY G.RAVINDER GOUD SA(MATHS) MPUPS RAVULA PALLY CHEVELLA RANGA REDDY 14860-39145 H.No.6-52

ENTER YOUR DETAILS HERE IN BLUE CELLS

HOUSE ADDRESS

BHAVANI NAGAR COLONY,SINGAPUR(M)SHANKER PALLY RANGA REDDY

INPATIENT / OUT PATIENT SPELL OF CLAIM NAME OF DISEASE HOSPITAL NAME HOSPITAL ADDRESS PERIOD OF TREATMENT AMOUNT

Inpatient FIRST

MATERNITYPREMIER HOSPITAL NANAL NAGAR X ROAD,MAHIDIPATNAM-HYD

FROM 15-05-2010 38,856 TO TO 21-05-2010

In One lakh forty two thousand words

DDO OFFICE NAME MANDAL DISTRICT

MEO,CHEVELLA MRC CHEVELLA CHEVELLA RANGA REDDY

BELOW 25000/TO ADDRESS ABOVE 25000/The Director of School Education, A.P., Near Telephone Bhavan, Saifabad, Hyderabad-500004

The District Educational Officer, Medak District, HQ:Sangareddy. 1.Appendix-II 2.Checklist 3.Emergency certificate 4.Essentiality certificate 5.Discharge summary 6.Original Medical Bills 7.Non Drawn certificate 8.Spell of claim certificate 9.Dependant certificate

ENCLOSURES

OFFICE OF THE MEO,CHEVELLA, MRC CHEVELLA DISTRICT: RANGA REDDY

From: The MEO,CHEVELLA, MRC CHEVELLA, Disrtict RANGA REDDY. Sir, Sub:Medical Attendance - Inpatient Medical Reimbursement of Sri/Smt.G.PADMA LATHA, WIFE of Sri/Smt.G.RAVINDER GOUD, SA(MATHS), MPUPS RAVULA PALLY, Mandal:CHEVELLA, Dist:RANGA REDDY - Submission for sanction - regarding. 1) G.O.Ms.No.74, Dated:15-03-2005. 2) G.O.Ms.No.40, Dated:07-05-2002. 3) Individuals Application Dated:.. ababababab To The Director of School Education, A.P., Near Telephone Bhavan, Saifabad, Hyderabad-500004 Dated:..

Lr.No

Ref:-

With reference to the subject cited above I submit here With the Inpatient Medical Reimbursement proposals of Sri/Smt.G.PADMA LATHA, WIFE of Sri/Smt.G.RAVINDER GOUD, SA(MATHS), MPUPS RAVULA PALLY, Mandal:CHEVELLA, Dist:RANGA REDDY. He/She was under gone treatment for MATERNITY- at PREMIER HOSPITAL, NANAL NAGAR X ROAD,MAHIDIPATNAM-HYD, from:15-05-2010 to 21-052010. I submit herewith the original bills, necessary documents for reimbursement of medical expenses of above treatment. Kindly scrutinize the bills and take necessary action for sanction. Thanking you. Early action solicited. Yours faithfully MEO,CHEVELLA MRC CHEVELLA Encl:1.Appendix-II 2.Checklist 3.Emergency certificate 4.Essentiality certificate 5.Discharge summary 6.Original Medical Bills 7.Non Drawn certificate 8.Spell of claim certificate 9.Dependant certificate

Dated: To The MEO,CHEVELLA, MRC CHEVELLA, Disrtict RANGA REDDY. Sir, Sub:Medical Attendance - Inpatient Medical Reimbursement of Sri/Smt.G.PADMA LATHA, WIFE of Sri/Smt.G.RAVINDER GOUD, SA(MATHS), MPUPS RAVULA PALLY, Mandal:CHEVELLA, Dist:RANGA REDDY - Submission for sanction - regarding. 1) G.O.Ms.No.74, Dated:15-03-2005. 2) G.O.Ms.No.40, Dated:07-05-2002. 3) Individuals Application Dated:.. ababababab

Ref:-

With reference to the subject cited above I submit here With the Inpatient Medical Reimbursement proposals of Sri/Smt.G.PADMA LATHA, WIFE of Sri/Smt.G.RAVINDER GOUD, SA(MATHS), MPUPS RAVULA PALLY, Mandal:CHEVELLA, Dist:RANGA REDDY. He/She was under gone treatment for MATERNITY- at PREMIER HOSPITAL, NANAL NAGAR X ROAD,MAHIDIPATNAM-HYD, from:15-05-2010 to 21-052010. I submit herewith the original bills, necessary documents for reimbursement of medical expenses of above treatment. Kindly forward the bills to The Director of School Education, A.P., Near Telephone Bhavan, Saifabad, for sanction. Thanking you. Early action solicited. Yours faithfully

Encl:1.Appendix-II 2.Checklist 3.Emergency certificate 4.Essentiality certificate 5.Discharge summary 6.Original Medical Bills 7.Non Drawn certificate 8.Spell of claim certificate 9.Dependant certificate

( G.RAVINDER GOUD ) SA(MATHS) MPUPS RAVULA PALLY Mandal:CHEVELLA

CHECK LIST FOR SUBMISSION OF MEDICAL ADVANCE / REIMBURSEMENT CLAIMS OF GOVERNMENT SERVANTS 1 2
Name of the Employee and Designation

G.RAVINDER GOUD, SA(MATHS), MPUPS RAVULA PALLY, MANDAL: CHEVELLA, DISTRICT:RANGA REDDY

Name of the Patient and relationship with the G.PADMA LATHA, employee

WIFE

Name of the Disease

MATERNITY-

Whether disease was covered in G.O.Ms.No.161 Fin& Plg Dt:05-05-2000, If so enclose admissibility certificate Whether the patient has been referred to NIMS / SWIMS in case the disease is not covered in G.O.Ms No.86 Dt:01-06-1992 Whether the patient underwent treatment in a hospital is a recogni-zed as per Govt. Orders or Not Whether the patient has been referred by NIMS / SWIMS in case the hospital is a recognized as per Govt. Orders

Yes

No

6 7

Yes Emergency certificate enclosed

If not referred by NIMS / SWIMS justified reaMothers and nature of urgency of Emergency certificate Enclosed obtaining treatment in recognized hospital as per G.O.175 H&M Dt:29-06-1997 Whether enclosed estimation certificate in case of advance / Essentiality certificate in case of Reimbursement Whether the bills have been counter signed by the concerned Head of the Department in NIMS / SWIMS in case of Medical Reimbursement

Yes- Essentiality certificate enclosed

10 11 12 13

No

Amount of advance / Reimbursement Rs.38856/required Whether the claim has been preferred within Yes six months Remarks of the Recommending Officer Recommended for sanction

MEO,CHEVELLA MRC CHEVELLA

APPENDIX II
Application for claiming refund of Medical Expenses incurred by the Government Servant and their Families 1 2 3 4 5 Name, Designation & Section Office in which employed Pay of the Government Servant defined in FR and other emoluments which should be shown separately Place of Duty G.RAVINDER GOUD, SA(MATHS), MPUPS RAVULA PALLY, MANDAL: CHEVELLA, DISTRICT:RANGA 14860-39145

6 7 8

MPUPS RAVULA PALLY, MANDAL: CHEVELLA, DISTRICT:RANGA H.No.6-52 Full residential address with Door No. BHAVANI NAGAR and Name of the Mohalla RANGA REDDY Name of the patient and relation ship G.PADMA LATHA, WIFE with Government Servant At School Place at which the patient fell ill Nature of illness and its duration
MATERNITY-

from:15-05-2010 to 21-05-2010 9 10 11
Details of Amount claimed cost of medicines purchased / list of cash memos Essentiality certificate enclosed and the essentiality certificate signed by treatment doctors

Total Amount claimed Rs. List of Enclosures

Rs.38856/Enclosed

Declaration to be signed by the Government Servant

I here by declare that the statement in this application are true to the best of my knowledge and belief and that the others from whom medical expenses were incurred is a member of my family as defined under the Government Medical Attendance Rules and wholly dependant upon me.

Signature of Government Servant And Office to which attested MEO,CHEVELLA

MRC CHEVELLA

NONDRAWN CERTIFICATE
This is to certify that the amount claimed towards Medical Reimbursement for the treatment of MATERNITY- at PREMIER HOSPITAL, NANAL NAGAR X ROAD,MAHIDIPATNAM-HYD from:15-05-2010 to 21-05-2010 in respect of Sri/Smt.G.PADMA LATHA, WIFE of Sri/Smt.G.RAVINDER GOUD, SA(MATHS), MPUPS RAVULA PALLY, Mandal:CHEVELLA, Dist:RANGA REDDY for Rs.38856/- (Rupees One lakh forty two thousand only) is the first time and not claimed previously.

Place:CHEVELLA Dated:

( G.RAVINDER GOUD ) SA(MATHS) MPUPS RAVULA PALLY Mandal:CHEVELLA

Attested MEO,CHEVELLA MRC CHEVELLA

DEPENDANT DECLARATION
Sri/Smt.G.PADMA LATHA, WIFE of Sri/Smt.G.RAVINDER GOUD, SA(MATHS), MPUPS RAVULA PALLY, Mandal:CHEVELLA, Dist:RANGA REDDY is wholly dependant upon me. She/He was under gone treatment for MATERNITY- at PREMIER HOSPITAL, NANAL NAGAR X ROAD,MAHIDIPATNAM-HYD from:15-05-2010 to 21-05-2010 and I incurred total expenditure.

Place:CHEVELLA Dated:

( G.RAVINDER GOUD ) SA(MATHS) MPUPS RAVULA PALLY Mandal:CHEVELLA

Attested MEO,CHEVELLA MRC CHEVELLA

SPELL OF CLAIM CERTIFICATE

Medical Reimbursement of Sri/Smt.G.PADMA LATHA, WIFE of Sri/Smt.G.RAVINDER GOUD, SA(MATHS), MPUPS RAVULA PALLY, Mandal:CHEVELLA, Dist:RANGA REDDY is FIRST spell of claim. She/He was under gone treatment for MATERNITY- at PREMIER HOSPITAL, NANAL NAGAR X ROAD,MAHIDIPATNAM-HYD from:15-05-2010 to 21-05-2010. Place:CHEVELLA Dated:

( G.RAVINDER GOUD ) SA(MATHS) MPUPS RAVULA PALLY Mandal:CHEVELLA

Attested MEO,CHEVELLA MRC CHEVELLA