MEDICAL REIMBURSEMENT PROPOSALS SOFTWARE FOR RETIRED TEACHERSAP

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: Sri. V.RAVI KUMAR

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#Employee Code : 0827448Designation : SEC. GR. TEACHERDate of Retirement : 30.10.2010P.P.O. Number : ABJ265353Bank Account Number : 52065498923Bank Name : State Bank of HyderabadBranch Name : BuchireddypalemSTO Code : 0809STO Place : Buchireddypalem

Place of Working : MPPP School Village : Pedaputhedu (H/W)

Name of the Mandal : DagadarthiName of the District : SPSR NelloreIs it for Dependent / Self : DependentName of the Patient : Smt. V.SuneethaRelation with the Employee : Wife Age : 26 YearsName of the Hospital : Bollineni Ramanaiah Memorial Hospitals Pvt. Ltd.Place of the Hospital : NelloreIs it Recongised / Private : Recognised

: No

Name of the Treatment : Malaria with Hypertention, old Asxiety Neurosis

Duration (DD/MM/YYYY) : From : 17.07.2010 To : 20.07.2010Total Expenditure : Rs. : 26000.00 / -No. of Spell : FirstHouse Address :

H.No. : B2-85 Mandal : BuchireddypalemStreet : Vidya Sadanam Street District : SPSR Nellore

Village & Post : Buchireddypalem Pincode : 524305Contact No : 9441766767

Pension Particulars of Employee : PAYPay : 12910

AI/FP :DA/DR : 2100

HRA : 1291HMA : 100

Others :Total : 16401

Name of the D.D.O : Sri. V.Indrasena Reddy, M.sc., M.Ed., M.Phil.

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Name of the Employee (In Block Letters)

Is it DENTAL / EYE (Mention 'Yes' or 'No')

Enter Last Pay

Particulars (or) Present

Pension Details

APUSSPSR NELLORE DISTRICT UNITAPUS DAGADARTHI MANDAL UNIT

MEDICAL REIMBURSEMENT PROPOSALS SOFTWARE FOR RETIRED TEACHERSAP

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ఇట్లు�

Ch. Venkateswarlu, Gen. Sec., APUS Nellore Dt.

NOTE :- →→ Please Verify the Proposals with Experts before Submission→ For Your Valuable Suggestions Please contact

A.Satish babu, Sec. Gr. Teacher

MY SPECIAL THANKS TO……………1)2)3)

4)5)6)7)

APUS # APUS # APUS # APUS # APUS # APUS # APUS # APUS # APUS # APUS # ఉపాధ్యా�యబంధ్లువులక్లు, ఆత్మీ�యతా నమస్కా�రాల్లు !

మిత్లు� లారా ! మన జిలా� రిటైర్డ్! ఉపాధ్యా�య్లుల మెడికల్ రియింబర్సమెంట్ ప్రపోజల్్స కోసం ఆపస్ జిలా� శాఖ అన్ని4హంగ్లులతో, సరి కో8 త్తగా,

నూతనస్కాఫ్ట్= వేర్డ్ తయార్లుచేయడం జరిగినది. ఈ సద్లుపాయాన్ని4 అందర్లు ఉపాధ్యా�య్లుల్లు ఉపయోగించ్లుకొన్ని , దీన్నిపై ఏమైనాసూచనల్లు, సలహాల్లు ఇవ్వలన్లుకొంటే క్రి8ంది అడ్రెTస్ న్లు సంప్రదించగలర్లు.

మీ..

To Unprotect the Sheets Password "VANDEMATHARAM"

MPP School, Thadakulu (G/C), Dagadarthi (Md), SPSR Nellore(Dt).

Mobile No. 9441766767E-Mail ID :- satishbabuambati@yahoo.co.in

Ch. V. Krishnareddy, President, APUS Nellore Dt.G.Mallikhrjunareddy, HM, ZPPHS, Kattubadipalem of Chennuru, Dagadarthi (Md).A.Penchalaiah, SA (Maths), ZPPHS, Kattubadipalem of Chennuru, Dagadarthi (Md).K.Subbarao, PET, ZPPHS, Kattubadipalem of Chennuru, Dagadarthi (Md).P.V. Ravi kumar, KavaliY.Mahesh, Gen. Sec. APUS Dagadarthi MandalK.Surya Narayana, Treasurer, APUS, ASPeta Mandal

ఇట్లు�

Ch. Venkateswarlu, Gen. Sec., APUS Nellore Dt.

Please Verify the Proposals with Experts before Submission

MY SPECIAL THANKS TO……………

మన జిలా� రిటైర్డ్! ఉపాధ్యా�య్లుల మెడికల్ రియింబర్సమెంట్ ప్రపోజల్్స కోసం ఆపస్ జిలా� శాఖ అన్ని4హంగ్లులతో, సరి కో8 త్తగా,

ఈ సద్లుపాయాన్ని4 అందర్లు ఉపాధ్యా�య్లుల్లు ఉపయోగించ్లుకొన్ని , దీన్నిపై ఏమైనా

మీ..

VANDEMATHARAM"

, HM, ZPPHS, Kattubadipalem of Chennuru, Dagadarthi (Md)., SA (Maths), ZPPHS, Kattubadipalem of Chennuru, Dagadarthi (Md).

PET, ZPPHS, Kattubadipalem of Chennuru, Dagadarthi (Md).

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#Designation of the D.D.O : Mandal Educational Officer

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D.D.O. Code : 08090308004

: Kavali Division

D.D.O. Place of Working : MPP DagadarthiDate of Proposals Submission : 24.09.2010Proceedings Rc.No. : 6/Edu/2010

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Prepared & Desiged by :

If D.D.O is Dy.E.O., Mention Name of the Divison

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Rc.No. 6/Edu/2010 Date : 24.09.2010

From To V.Indrasena Reddy, M.sc., M.Ed., M.Phil., The District Educational OfficerMandal Educational Officer, SPSR Nellore (Dt.)MPP, Dagadarthi, Andhra PradeshDagadarthi Mandal, SPSR Nellore (Dt.).

Respected Sir

Sub :-

Ref : - 1. A.P. Integrated Medical Affairs rules, 1972.2. G.O. Ms.No. 40, Edn (Ser ) Dept, dt. 07.05.20023. G.O. Ms.No. 74, M&H Dept., dated: 15-03-2005.4. G.O.Ms.No. 105, M&H Dept., dated: 09-04-2007.5. G.O.Ms.No. 68, M&H Dept., dated: 28.03.2011.6. Representation of the Individual.

Thanking you Sir,

Enclosures : 1. Representation of the Individual 2. Appendix - II 3. Annexure - II 4. Form - "C" 5. Check List 6. Non Drawal & Availment Certificates Yours faithfully 7. Dependent Certificate 8. Proforma - E 9. Pension Payment Order10. Genuineness Certificate Mandal Educational Officer11. Emergency Certificate MPP, Dagadarthi12. Essentiality Certificate

Primary Education - MPP, Dagadarthi, SPSR Nellore (Dt.) - Reimbursement of

Medical Expenses of Smt. V.Suneetha, W/o Sri. V.RAVI KUMAR, Retired SEC.

GR. TEACHER, MPPP School, Pedaputhedu (H/W), Dagadarthi Mandal, SPSR

Nellore (Dt.) for Rs. 26000 /- - Sanction Request - Reg.

I Submit here with the Medical Reimbursement Claim of Rs. 26000/- ( Inwords Twenty Six Thousand Rupees ) Submitted by Sri. V.RAVI KUMAR, Retired SEC. GR. TEACHER, MPPP School, Pedaputhedu (H/W), Dagadarthi Mandal, SPSR Nellore (Dt.) for favour of Sanction of Medical Reimbursement of the Medical Expenses incurred by him. His Wife was admitted in Bollineni Ramanaiah Memorial Hospitals Pvt. Ltd., Nellore and underwent Treatment for Malaria with Hypertention, old Asxiety Neurosis in Emergency condition.

I Submit herewith the Representation of Sri. V.RAVI KUMAR, Retired SEC. GR. TEACHER, MPPP School, Pedaputhedu (H/W), Dagadarthi Mandal with the following enclosures to accord sanction at your earliest convenience.

13. Discharge Summary14. Medical Bills

Date : 24.09.2010

From ToSri. V.RAVI KUMAR The District Educational Officer,

Retired SEC. GR. TEACHER, SPSR Nellore (Dt.),

MPPP School, Pedaputhedu (H/W), Andhra Pradesh.

Dagadarthi Mandal, SPSR Nellore (Dt.).

THROUGH The Mandal Educational Officer, MPP, Dagadarthi.

Respected Sir,

Sub :-

So, I Humbly Requested to sanction me the Reimbursement claim for the amount

mentioned above for which I am eligible.

Thanking you Sir,

Enclosures : Yours faithfully

1. Appendix - II

2. Annexure - II

3. Form - "C" ( V.RAVI KUMAR ) 4. Check List Retired SEC. GR. TEACHER, MPPP School

5. Non Drawal & Availment Certificates Pedaputhedu (H/W), Dagadarthi Mandal.

6. Dependent Certificate

7. Proforma - E

8. Pension Payment Order

9. Genuineness Certificate

10. Emergency Certificate

11. Essentiality Certificate

12. Discharge Summary

Primary Education - MPP, Dagadarthi, SPSR Nellore (Dt.) - Smt. V.Suneetha, W/o Sri. V.RAVI KUMAR, Retired SEC. GR. TEACHER, MPPP School, Pedaputhedu (H/W), Dagadarthi Mandal, SPSR Nellore (Dt.) Treatment for Malaria with Hypertention, old Asxiety Neurosis - Sanction Medical Reimbursement Requested - Regarding.

I am Worked as SEC. GR. TEACHER, MPPP School, Pedaputhedu (H/W), Dagadarthi Mandal, SPSR Nellore (Dt.). and Retired in the Same School on 30.10.2010. On Emergency basis due to Malaria with Hypertention, old Asxiety Neurosis. My Wife was Admitted in Bollineni Ramanaiah Memorial Hospitals Pvt. Ltd., Nellore.

Treatment was done from 17.07.2010 to 20.07.2010. She has been under gone Treatment

at Bollineni Ramanaiah Memorial Hospitals Pvt. Ltd., Nellore and that Service of Treatment for

which the Expenditure is Rs. 26000 /- ( Inwords Twenty Six Thousand Rupees )

13. Medical Bills

APPENDIX – II

1 :V.RAVI KUMARRETIRED SEC. GR. TEACHER

2 Office in which Employed :MPPP School, Pedaputhedu (H/W)

Dagadarthi Mandal, SPSR Nellore (Dt.)

3 :PAY + AI/FP+ DA + HRA + HMA+ OTHERS TOTAL

12910 0 2100 1291 100 0 16401

4 Place of Duty :MPPP School, Pedaputhedu (H/W)Dagadarthi Mandal, SPSR Nellore (Dt.)

5 :H.NO.B2-85, Vidya Sadanam StreetBuchireddypalem (Vil&Po), Buchireddypalem MandalSPSR Nellore (Dt.), A.P. PIN :524305

6 :Smt. V.Suneetha, Wife

7 Place at which the patient fell ill :

8 Nature of illness and its duration :Malaria with Hypertention, old Asxiety Neurosis

From: 17.07.2010 To: 20.07.2010

9 :

Rs. 26000 / -

10 Total amount claimed : Rs. 26000 / -

11 List of Enclosures :

1. Annexure - II 2. Form - "C" 3. Check list 4. Non Drawal & Availment Certificates 5. Dependent Certificate 6. Proforma - E 7. Pension Payment Order 8. Genuineness Certificate 9. Emergency Certificate10. Essentiality Certificate11. Discharge Summary12. Medical Bills

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 (in block letters)

Pay of the Government Servant as defined in F.Rs. and other employments which should be shown separately

Full Residential Address with door number, name of the Mohalla and DistrictName of the Patient, his/her relationship to the Government Servant, in case of children state age also

Bollineni Ramanaiah Memorial Hospitals Pvt. Ltd., Nellore

Details of amount claimed, cost of Medicines purchased from the market/ list of Medicines purchased with cash memos, and the Essentiality Certificate should be attached each in duplicate signed

All original Bills with Counter siged by the Docter are Enclosed

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 on me.

SIGNATURE OF THE FORWARDING AUTHORITY

SIGNATURE OF THE GOVT. SERVANT

ANNEXURE - ll

1 :V.RAVI KUMAR

RETIRED SEC. GR. TEACHER

2 Office in which Employed :MPPP School, Pedaputhedu (H/W)

Dagadarthi Mandal, SPSR Nellore (Dt.)

3 Salary :PAY + AI/FP+ DA + HRA + HMA+ OTHERS TOTAL

12910 0 2100 1291 100 0 16401

4 Place of Duty :MPPP School, Pedaputhedu (H/W)

Dagadarthi Mandal, SPSR Nellore (Dt.)

5 Full Residential Address :H.NO.B2-85, Vidya Sadanam Street

Buchireddypalem (Vil&Po), Buchireddypalem Mandal

SPSR Nellore (Dt.), A.P. PIN :524305

6 : Smt. V.Suneetha, Wife

7 Nature of illness and its duration :Malaria with Hypertention, old Asxiety Neurosis

From: 17.07.2010 To: 20.07.2010

8 Details of amount claimed :Rs. 26000 / -

9 Total amount claimed : Rs. 26000 / -

Name, Designation & Section of Government Servant (in block letters)

Name of the Patient, his/her relationship to the Government Servant, in case of children state age also

All original Bills with Counter siged by the Docter are Enclosed

SIGNATURE OF THE FORWARDING AUTHORITY

SIGNATURE OF THE GOVT. SERVANT

FORM - "C"(Vide Rule 15 (3))

APPLICATION FOR CLAIMING REFUND OF MEDICAL EXPENSES

1 : V.RAVI KUMARRETIRED SEC. GR. TEACHER

2 Office in which Employed :MPPP School, Pedaputhedu (H/W)Dagadarthi Mandal, SPSR Nellore (Dt.)

3 Salary :PAY + AI/FP+ DA + HRA + HMA+ OTHERS TOTAL

12910 0 2100 1291 100 0 16401

4 Place of Duty :MPPP School, Pedaputhedu (H/W)Dagadarthi Mandal, SPSR Nellore (Dt.)

5 Full Residential Address :H.NO.B2-85, Vidya Sadanam StreetBuchireddypalem (Vil&Po), Buchireddypalem MandalSPSR Nellore (Dt.), A.P. PIN :524305

6 :Smt. V.Suneetha, Wife

7 Place at which the patient fell ill :

8 Nature of illness and its duration :Malaria with Hypertention, old Asxiety Neurosis

From: 17.07.2010 To: 20.07.2010

9 Details of amount claimed :Rs. 26000 / -

10 Total amount claimed : Rs. 26000 / -

11 List of Enclosures :

1. Appendix - ll 2. Annexure - ll 3. Check list 4. Non Drawal & Availment Certificates 5. Dependent Certificate 6. Proforma - E 7. Pension Payment Order 8. Genuineness Certificate 9. Emergency Certificate10. Essentiality Certificate11. Discharge Summary

12. Medical Bills

Name, Designation & Section of Government Servant (in block letters)

Name of the Patient, his/her relationship to the Government Servant, in case of children state age also

Bollineni Ramanaiah Memorial Hospitals Pvt. Ltd., Nellore

All original Bills with Counter siged by the Docter are Enclosed

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 on me.

SIGNATURE OF THE FORWARDING AUTHORITY

SIGNATURE OF THE GOVT. SERVANT

CHECK SLIP FOR SENDING MEDICAL REIMBURSEMENT PROPOSALS

1 Name and Address of the Employee : V.RAVI KUMARRETIRED SEC. GR. TEACHERMPPP School, Pedaputhedu (H/W)Dagadarthi Mandal, SPSR Nellore (Dt.)

Employee Code : 08274482 If Retired

a) Date / Year of Retirement : 30.10.2010b) Designation : SEC. GR. TEACHERc) P.P.O. No. : ABJ265353

3 : H.NO.B2-85, Vidya Sadanam StreetBuchireddypalem (Vil & Po),Buchireddypalem Mandal,SPSR Nellore (Dt.), A.P. PIN:5243059441766767

4 Name and Address of the Hospital :Nellore

a) : Recognised

b) : Yes

5 : Yes

6 Whether the Following are enclosed :i) Appendix to duly attested by the head of the Office : Yesii) Emergency Certificate : Yesiii) Discharge summary : Yesiv) Non-Drawl certificate : Yesv)

: Yes

vi)

: Yes

7: Not

8: Yes

9 : Yes

10 : Recorded

11 : Yes

Comminication of the Applicant Address for all Purpose wiith Cell No.

Bollineni Ramanaiah Memorial Hospitals Pvt. Ltd.

Whether it is Private Hospital (or) Recongnised HospitalWhether Referral letter Produced (or) Recongnised orders to be Enclosed along with the Proposal

Whether the Medical Reimbursement Proposal sent with in 6 months from the date of discharge

Essentiality certificate attested by the authorised doctor who under takes treatmentIf the patient is dependent on the Govt. Empolyee, Un-employee certificate and Dependency certificate are to be enclosed with the Reimbursement ProposalIn case of dependents of deceased Govt. Employee /

retired employee whether legal heir certificate is enclosed (or) not

whether the Medical Reimbursement Proposal is is prepared and submitted with reference to GO.Ms.No .74 HM & FW (K1) Dept. dated 15.3.05, GO.Ms.No.60 HM & FW (K1) Dept. dt.15.10.03 and GO.Ms.No.105HM & FW (K1) Dept.

whether the medical reimbursement claim is processed through the DDO and received with in the stipulated time Whether the availment of No. of Installments recorded (or) notWhether the an entry is made in the service register (or) not for previous claim and drawl

SIGNATURE OF THE GOVT. SERVANT

SIGNATURE OF THE FORWARDING

AUTHORITY

AVAILMENT CERTIFICATE

This is to certify that Sri. V.RAVI KUMAR, Retired SEC. GR. TEACHER, MPPP School, Pedaputhedu (H/W), Dagadarthi Mandal, SPSR Nellore (Dt.) is Submitted Medical Reimbursement Proposals for his Wife treatment at Bollineni Ramanaiah Memorial Hospitals Pvt. Ltd., Nellore for First time only.

SIGNATURE OF THE GOVT. SERVANT

SIGNATURE OF THE FORWARDING AUTHORITY

NON-DRAWAL DECLARATION

Station : Buchireddypalem (V.RAVI KUMAR) H.No. B2-85, Vidya Sadanam Street

Buchireddypalem (Vil), Buchireddypalem MandalDate : 24.09.2010 Phone No. 9441766767

Station : MPP, Dagadarthi Date : 24.09.2010

Postal Address of the Office :Sri. V.Indrasena Reddy, M.sc., M.Ed., M.Phil.Mandal Educational Officer DDO Code : 08090308004MPP, Dagadarthi STO Code : 0809Dagadarthi Mandal, SPSR Nellore (Dt.)

I V.RAVI KUMAR, Retired. SEC. GR. TEACHER, MPPP School, Pedaputhedu (H/W), Dagadarthi Mandal Receiving the Service Pension vide P.P.O. No. ABJ265353 with A/C No. 52065498923 in State Bank of Hyderabad, Buchireddypalem is hereby declare that , I am not Claimed Previously the amount of Rs. 26000 /- (Rupees Twenty Six Thousand Rupees Only) from the Department towards the Reimbursement of Medical Incurred for The Treatment of My Wife V.Suneetha for Recovery of Malaria with Hypertention, old Asxiety Neurosis during the Period from 17.07.2010 to 20.07.2010 at Bollineni Ramanaiah Memorial Hospitals Pvt. Ltd. and Not Received any Part of the above amount so far.

Further, I Declare that , It is the First time Claim during My Entire Service and after Retirement Period.

Certified that the amount of Rs. 26000 /- (Rupees Twenty Six Thousand Rupees Only) Furnished by the Applicant in the above declaration has not been Drawn from STO Buchireddypalem and Disbursed to him as per Available Records of this Office and also with Reference to the Records of the Treasury Office.

SIGNATURE OF THE FORWARDING AUTHORITY

DEPENDENT CERTIFICATE

PHOTO OF THE DEPENDENT

Smt. V.Suneetha W/o Sri. V.RAVI KUMAR,

Retired SEC. GR. TEACHER, MPPP School,

Pedaputhedu (H/W), Dagadarthi Mandal, SPSR

Nellore (Dt.). is not Employee / Pensioner and fully

dependent on me and she has no other source of

Income and completely dependent on me.

SIGNATURE OF

THE GOVT. SERVANT

SIGNATURE OF THE FORWARDING AUTHORITY

PROFORMA - E

1 S.No. : 1

2 Name and Designation :

V.RAVI KUMAR

Retired SEC. GR. TEACHER

3 Place of Work :

MPPP School, Pedaputhedu (H/W)

Dagadarthi Mandal, SPSR Nellore (Dt.)

4 Name of the Disease :

5 Peroid : From: 17.07.2010 To: 20.07.2010

6 Amount : Rs. 26000 / -

7 Spell : First

8 Entered in Service Register : Yes

9 : Yes

Malaria with Hypertention, old Asxiety Neurosis

Entered in Reimbursement Register

SIGNATURE OF THE GOVT. SERVANT

SIGNATURE OF THE FORWARDING AUTHORITY