DEPENDENT DECLARATION CERTIFICATE Sri/Smt... Son/Daughter/Spouse/Parents of Sri/Smt/Kum...Designation. of school..village,.mandal, Prakasam District has not an employee/pensioner & fully dependent on me and... he/she has no other source of income and completely depended on me. STATION:: DATE: SIGNATURE & DESIGNATION OF THE APPLICANT Signature of the forwarding authority SELF DECLARATION CERTIFICATE I...................... S/o,D/o,W/o...................... hereby declare that my self...................... aged............ years has no property or income from any other sources and that I am wholly dependant upon my salary. STATION:: DATE :: SIGNATURE & DESIGNATION
FORWARDING LETTER Office of the Rc.No. Date: From To Sub: Medical Reimbursement proposal of Sri/Smt _ at School Village Mandal, Prakasam District.... Ref: 1) G.O.Ms.No 74, Dated: 15 03 2005, Health Medical and Family Welfare (k1)dept., 2) G.O Ms.No.105 HM&FW(K1)Dept. Dated:9.4.2007 3)Letter of the individual Date: @ @ @ According to the above subject and references cited above I am herewith submitting the Medical reimbursement proposals of Sri/Smt _Mandal in the prescribed proformas in Triplicate for necessary action. Enclosures: Thanking you Sir, 1.Checkist for Medical Advance/ Reimbursement 2. Application of the individual 3. Appendix II duly countersigned by the controlling officer 4. Dependent certificate/self declaration 5. Essential certificate issued by the concerned Hospital. 6. Total expenditure statement bills abstract. 7. Medical bills in original duly counter signed by the treating doctor. Yours faithfully, 8. Orders in which the claim of the individual is covered copy of the orders of the Govt. Recognition. 9. Undertaking authority that the particulars furnished by the individual is true and the individual is not claimed the medical reimbursement/ advance for the same disease earlier during the same period. 10. Emergency certificate issued by the concerned hospital 11. Discharge summary/case report/ discharge memo in original 12. Pension sansion orders(photostat copy) 13. Esimation certificate for advance 14. Advance certificate 15. Referal letter from the superintendent of district government hospital
APPENDIX II APPLICATION FOR CLAIMING REFUND OF MEDICAL EXPENSES INCURRED IN CONNECTION WITH MEDICAL ATTENDANCE OR TREATMENT OF GOVERNMENT SERVANT AND THEIR FAMILIES 1.Name and Designation & Section. : (in BLOCK letters) 2.Office in which employed. : 3.Pay of Government Servant as defined in Pay D.A H.R.A Total F.Rs and other employments which should : Be shown separately. 4.Place of duty. : 5.Full residential address with Door No.and : Name of the Mohalla. 6.Name of the patient, his/her relationship to The Govt. Servant. In case of children state : Age also. 7.Place at which the patient fell 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 Should be enclosed. 10.Total amount claimed. : 11.List of enclosures. :1.Essentiality Certificate 2.Discharge Memo 3.Medical Bills 4.Check list 5.Dependent/self declaration DECLARATION TO BE SIGNED BY THE GOVT.,SERVANT I hereby declare that the statement in this application is true to the best of my knowledge and belief and the person from whom medical expences were incurred is a member of my family as defined under the Government servant Medical attendance rules 1972 and wholly dependent upon me. Counter signed by the D.D.O Signature of the Govt.,Servant and office to which attached.
CHECK LIST FOR SUBMISSION OF MEDICAL REIMBURSEMENT 1. Name of the Employee and Designation :: 2. Name of the patient and relationship :: with employee 3. Name of disease 4. Whether disease covered G.O.Ms.No. :: 86 Fin&Plg,Dt.1.6.92, if so,admissibility Certificates should be enclosed. 5. Whether the patient has been referred to :: NIMS/SVIMS in case of the disease is not Covered in G.O.Ms.No.86, Dt.1.6.92. 6. Whether the patient underwent treatment :: Hospital is a recognized Hospital as per Govt.,Orders. 7. Whether the patient has been referred by :: NIMS/SVIMS in case of treatment taken In the hospital organized by Govt., 8. If not, referred by NIMS/SVIMS, justified :: Reasons and nature of the urgency of Obtaining treatment in recognized hospital as per G.O.Ms.No.175 H&M,Dt.29.5.97. 9. Whether enclosed Essentiality Certificate :: In case of re imbursement. 10.Whether bills have been counter signed by :: The concerned Doctor/Head of Department In case of Medical Re imbursement. 11.Amount of re imbursement required, in :: Case of re imbursement in various hospitals Separate station to be shown. 12.Whether the claim has been reffered within:: 6 months. 13.Remarks of the recommending officer :: Signature of the D.D.O
NON DRAWAL /UNDER TAKING OF THE FORWARDING AUTHORITY CERTIFICATE Sri/Smt.Designation Of school.village. mandal,prakasam district has not claimed the amount of Rs.(in words)..ie.,from. To previously and this is the spell for....disease and entered in Medical Re imbursement Register. Signature of the Government Servant Signature of the D.D.O EMERGENCY ADMISSION CERTIFICATE This is to certify that Mr./Mrs./Ms S/o,D/o,W/o.aged about.. Years admitted in our Hospital in..department Under emergency on at A.M/P.M. The provisional diagnosis is.. Signature and Designation of the Authorised Medical Attendnt.
TOTAL EXPENDITURE STATEMENT Sl.No. Date Bill No. Particulars Amount 115436.25 Total Rupees in Words: Counter signed by the D.D.O Signature of the applicant