medical bills formates 4-11-2011

8/3/2019 Medical Bills Formates 4-11-2011

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CHECK SLIP FOR SENDING MEDICAL REIMBURSEMENT PROPOSALS

Sl No Description of Details required Details submitted

1 2 3

1Name and official address of the

Employee

S. Ayaz Ahamed,

Asst.Executive Engineer,

P.I.U.(P.R) Sub-Division,

Panyam, Kurnool district.

2 Date of Treatment 14-9-2011 to 20-9-2011.

3 Name & address of Hospital

Cure Multi speciality Hospital,

N.G.Os colony road,

Noonepalli,

Nandyal.

Kurnool district.

4 whether private recognized or Govt.

5

whether the proposal is received in the head office

with in a period of six months from the date of

discharge

6Whether Appendix II attested by the head of the

officer is enclosed

7In case of treatment at recognized Hospital / NIMS /

SVIMS whether emergency certificate is enclosed.

8

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.

Yes

9

Whether the bills for the amount mentioned in the

essentially certificate attested by the Dr who

treated / A.M.A are enclosedYes

10Whether the discharge summery of the patient is

enclosedYes

11In case or retired Govt. employee whether the copy

of the pension payment order is enclosed.

12

In case of dependents above the age of 18 years

unemployment and dependency certificate counter

signed by the head of office is enclosed

13

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) : S.Ayaz Ahamed, Asst.Executive Engineer.and designation

2. Office in which employed : O/o Deputy Exe. Engineer, PIU (PR) S/D Panyam.

3. Pay of Govt sevant as defined as F.R.S :and other allowances which should be

shown separately.

4. Place of duty : Panyam-Gadivemula Mandals.

5. Full residential address with door No. : H.No. 27-192 A, Moolasagaram, Nandyal.

6. Name of the patient his / her relationship to : S.Ayaz Ahamed (self)Govt Servant

7. Place at which the patient fall ill : Nandyal.

8. Nature of illness and its duration : Road Accident.

9. Details of amount claimed, cost of : As per bills enclosed.medicines purchased from the

market / list of medicines cash memos

and the essentiality certificate

10. Total amount claimed for : Rs. 48790.00

11. List of enclosures :

a) Check list :

b) Appendix II :c) Essentiality certificate :

d) Cash memos, bills etc :

e) Emergency certificate :

f) Discharge summery :

// Attested //

S.Ayaz ahamed,

Dy. Executive Engineer, Asst. Executive Engineer,

PIU (PR) Sub-Division,Panyam. 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,


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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,


PIU (PR) Sub-Division,Panyam. PIU (PR) Sub-Division,Panyam.

Kurnool district.


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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.


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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. Particulars Rate Amount

1. Consultant charges for surgery and treatment. 36000.00

2. Accommodation charges 7000.00

3. Medicines 5790.00

Total Rs. 48790.00


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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,


PIU (PR) Sub-Division,Panyam. PIU (PR) Sub-Division,Panyam.

Kurnool district.

medical bills formates 4-11-2011

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