FROM TO

The Director of School Education

Andhra Pradesh
HYDERABAD

.
RC.No. /MR/2008, Dated: .

Sir
,
SUB: Education-Ele.Education-M.P.Piduguralla,Guntur
District.
Sri/Smt.
Submission of Medical Reimbursement Proposals-Req.-reg.

REF: 1) G.O.Ms.No.74 M.H.&F.W.Deptt. Dated.15-03-2005.

2.Rc.No. Dated: of the
Director of Medical Education, A.P. Hyderabad.
3) G.O.Ms.No. 105 H.M&F.W.(K1) Deptt. Dated:09.04.2007/
4) Application of the individual with connected papers.
-x-x-x-x-

I do here by submit that the proposals received from Sri./Smt.

regarding Medical Reimbursement of
exepenses incurred by the self/dependent who has been sufferring from
and got necessary investigations and treatment in the

nd
Which is declared as referral hospital as per reference 2 cited above during the period from
.

In pursuance of the incumbent’s genuine application for the reimbursement of

Medical expenses for the said treatment and investigation for Rs. /- (
) . I do hereby forward
his application along with the following connected papers so as to bring to your notice for
Favourable action for issuing necessaryorders regarding.

Thanking you
Enclosures sir, Yours faithfully,
:
1. Check list & Appendix-II
2. Essentiality&Emergency certificates
3. Discharge summary
4. Referral Hospital G.O.
5. Non-Drawal certificate
6.Original Bills & Abstract
 CHECK LIST FOR SENDING MEDICAL REIMBURSEMENT PROPOSALS

1. Name & Address of the Employee/Retired Employee :

2. Dates of Treatment : From To

3. Name & Address of the Hospital :

4. Whether Private Recognized by Government

(Private un-recognized proposals should not be sent) :

5. Whether the proposals is received in the Head of Office

Within a period of six months from the date of discharge? : YES / NO

6. Whether Appendix-II attested by the Head of the

Office is enclosed : YES / NO

7. In case of treatment in private recognized Hospital/

NIMS/SVIMS Whether referral letter/Emergency
Certificate is enclosed : YES / NO

8. Whether essentiality certificate mentioning the amount

Of expenditure for the treatment signed by the doctor
Who treated and attested by the authorized medical
Agency is enclosed : YES / NO

9. Whether the bills for the amount mentioned in the

Essentiality certificate attested by the doctor who treated/
Authorised Medical Agency are enclosed? : YES / NO

10.Whether the Discharge Summary of patient is enclosed : YES / NO

11. In case of retired Govt.Employee whether the copy

Of the Pension Payment Order is enclosed : YES / NO

12. In case of dependents above the age of 18 years un-

Employment and Dependency certificate counter signed by
The Head of the Office is enclosed. : YES / NO

13. In case of dependents of deceased Govt. Employee/retired

Employees whether Legal Heir Certificate is enclosed : YES / NO

Signature of the Head Office.

 APPENDIX --- II
Application for claiming refund of Medical Expenses incurred in connection with medical attendance
and or treatment of Government Servant and their families.

1. Name and Designation

(In Block Letters) :
2. Office in which employed :

3 Pay of the Govt.Servant as defined in PAY: D.A: H.R.A

. F.Rs. And other emoluments which :
should be Shown separately OTHERS: GRO
S S:
4 Place of duty :
.

5 Full residential address with D.No. and

. Name of the Mohalla :

6 Name of the patient him/her relationship to

. The Govt.servant(In case of children
Stage age) :

7 Place at which patient fall ill :

.
8 Nature of illness and its duration :
.
9 Details of amount claimed, cost of
. Purchased from the market, list of
medicines
medicines
Cash memos and the essentially certificate
Should be atached each in duplicate signed
By treatment doctor. :

10. Total amount claimed :

11. List of enclosures :

a) Essentiality Certificate ( ) b) Emergency certificate ( )

b) Discharge summary ( ) d)Medical Bills ( )

Declaration to be signed by the

Govt. Servant.
I hereby declare that the statement in this application are true to thebest of my knowledge and
belief and that the person from whom medical expenses were incurred is a member of my
Family as defined under the Govt.Servant Medical attendance rules and wholly dependent upon me.

Signature of the Govt.Servant

NON DRAWAL DECLARATION

I hereby declare that this amount has not been drawn and paid previously.

//Attested/
/ Signature of the Govt. Servant

Signature of the
M.E.O.
 NON-DRAWAL CERTIFICATE

This is to certify that the Medical Reimbursement Arrears

Rs. /- (

) was not drawn and paid previously.

//Attested//

Signature of the Govt. servant

Signature of the M.E.O./HM

 DEPENDENT CERTIFICATE
As per A.P Integrated Medical Attendance Rules 1972,Rule 3(7)b(ii)

I ,
of Guntur District(Full Name & Designation) here
by declare that My W/o,F/o,S/o, has no
Property or Income of her own and that she wholly dependent on me.

//Counter Signed// (Signature of Applicant)

District/Dy Educational Officer .