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CHECK SLIP FOR SENDING MEDICAL REIMBURSEMENT PROPOSALS

Sl No
1

Description of Details required


2 Name and official address of the Employee

Details submitted
3 S. Ayaz Ahamed, Asst.Executive Engineer, P.I.U.(P.R) Sub-Division, Panyam, Kurnool district. 14-9-2011 to 20-9-2011.

Date of Treatment

Name & address of Hospital

Cure Multi speciality Hospital, N.G.Os colony road, Noonepalli, Nandyal. Kurnool district.

whether private recognized or Govt. whether the proposal is received in the head office with in a period of six months from the date of discharge Whether Appendix II attested by the head of the officer is enclosed In case of treatment at recognized Hospital / NIMS / SVIMS whether emergency certificate is enclosed. Whether essential certificate mentioning the amount of expenditure for the treatment signed by the Dr. who treated and attested by the authorized medical agency is enclosed. Whether the bills for the amount mentioned in the essentially certificate attested by the Dr who treated / A.M.A are enclosed Whether the discharge summery of the patient is enclosed In case or retired Govt. employee whether the copy of the pension payment order is enclosed.

Yes

Yes Yes

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In case of dependents above the age of 18 years unemployment and dependency certificate counter signed by the head of office is enclosed In case of dependents of the diseased Govt. employees / retired employees, whether legal heirs is enclosed.

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APPENDIX II
APPLICATION FOR CLAIMING REFUND OF MEDICAL EXPENSES INCURRED CONNECTION ON WITH MEDICAL ATTENDANCE AND OR TREATMENT OF GOVERNMENT SERVANT AND THEIR FAMILIES 1. Name & Address ( in block letters)
and designation : S.Ayaz Ahamed, Asst.Executive Engineer.

2. Office in which employed 3. Pay of Govt sevant as defined as F.R.S 4.


and other allowances which should be shown separately. Place of duty

: O/o Deputy Exe. Engineer, PIU (PR) S/D Panyam. :

: Panyam-Gadivemula Mandals. : H.No. 27-192 A, Moolasagaram, Nandyal.

5. Full residential address with door No.


Govt Servant

6. Name of the patient his / her relationship to : S.Ayaz Ahamed (self) 7. Place at which the patient fall ill 8. Nature of illness and its duration 9. Details of amount claimed, cost of
medicines purchased from the market / list of medicines cash memos and the essentiality certificate : Nandyal. : Road Accident. : As per bills enclosed.

10. Total amount claimed for 11. List of enclosures a) b) c) d) e) f)


Check list Appendix II Essentiality certificate Cash memos, bills etc Emergency certificate Discharge summery

: Rs. 48790.00 : : : : : : :

// Attested // S.Ayaz ahamed, Asst. Executive Engineer, PIU (PR) Sub-Division,Panyam.

Dy. Executive Engineer, PIU (PR) Sub-Division,Panyam. Kurnool district.

I hereby declare that the statement given in this application is true to the best of my knowledge and that the person from whom medical expenses were incurred is a member of my family as defined under the Government servant medical attendance rules.

// Attested // S.Ayaz ahamed,

Dy. Executive Engineer, PIU (PR) Sub-Division,Panyam. Kurnool district.

Asst. Executive Engineer, PIU (PR) Sub-Division,Panyam.

DEPENDENCY CERTIFICATE
I hereby declare that the statement given in this application is true to the best of my knowledge and that the person from whom medical expenses were incurred is a member of my family as defined under the Government servant medical attendance rules and wholly dependent upon me.

// Attested // S.Ayaz ahamed, Asst. Executive Engineer, PIU (PR) Sub-Division,Panyam.

Dy. Executive Engineer, PIU (PR) Sub-Division,Panyam. Kurnool district.

EMERGENCY CERTIFICATE

This is to certify that Mr./Mrs./Ms. S.Ayaz Ahamed. Male/ Female, aged 42 years and S/W/D/M/F/H/o S.Yousuf was admitted in our hospital on 14-09-2011 in an

emergency condition under Dr. David Raju, M.S. ORTHO. The provisional diagnosis was fractured both bones of Left forearm.

ESSENTIALITY CERTIFICATE

I certify that Mr./Mrs./Ms S.Ayaz Ahamed (self) (employ) Male/ Female, Aged 42 years employed in the P.I.U.(P.R), Sub division, Panyam has been under my treatment for O R F I & Plating of both bones of left hand forearm from 14-09-2011 to 20-09-2011 at Cure Multi specialty Hospital, N.G.Os colony road, Noonepalli, Nandyal. and the below mentioned investigations/ Medicines prescribed by me in this connection were essential for recovery of patient. S.No. 1. 2. 3. Particulars Consultant charges for surgery and treatment. Accommodation charges Medicines Total Rs. Rate Amount 36000.00 7000.00 5790.00 48790.00

NON-DRAWAL CERTIFICATE

Certified that the claim of re-imbursement of medical expenses currently claimed by S.Ayaz Ahamed, Assistant Executive Engineer, PIU Sub-Division, Panyam for his treatment from 14-09-2011 to 20-09-2011 at Cure Hospital amounting Rs. 48790.00 (Rupees Forty eight thousand seven hundred and ninety only) was neither preferred nor drawn previously.

// Attested // S.Ayaz ahamed, Asst. Executive Engineer, PIU (PR) Sub-Division,Panyam.

Dy. Executive Engineer, PIU (PR) Sub-Division,Panyam. Kurnool district.