MEDICAL REIUMBURSEMENT FOR STATE GOVERNMENT EMPLOYEES PERSONAL DETAILS

Name of the Employee Designation Place of Working Name of the Mandal Name of the District Present Scale of Pay Present Basic Pay
Sri. 1

DOCUMENTS TO BE ENCLOSED
G.VENKATESWARLU Please select the documents that are enclosed with Bill
Essentiality Certificate TRUE Emergency Certificate TRUE Discharge Summary TRUE Investigation Report. TRUE Dependent Certificate TRUE Medicine Bills TRUE Check TRUE List. Non-Drawl Certificate TRUE

School Assistant 36

ZPHS KAVUR CHILAKALURIPET 7 Hyderabad District

14860-39540 17 14860 29

H.No. 16-1-178/A/9 Residential Address Hari Puri Colony Hyderabad PIN CODE 500072

PATIENT DETAILS
Name of the Patient Relationship with Employee Age of the Patient Name of the Hospital Category of the Hospital Name of the Treatment Amount of Hospital Bill in figures (Rs.) Date of Joing in the Hospital Date of Discharge Date of submission of Proposals to DDO
Baby. 1 Daughter 8

Y. Sarala

CLICK ON THE FOLLOWING LINKS

Letter to the D.D.O. Letter to the Higher Authorities Non-Drawl Certificate Check List for sending Proposals. Appendix - II Dependent Certificate.
Note: To unprotect the sheets from 1 to 6 password: TEACHER

15 Years LALITHA SUPERSPECIALITY, GUNTUR Private 2 Fever 20000 DD-MM-YYYY DD-MM-YYYY DD-MM-YYYY 01-07-2009 10-07-2009 22-08-2009

Developed By:
K. Sreenivas Reddy working on deputation at O/o the District Educational Officer, Hyderabad District.

D.D.O. DETAILS
Name of the D.D.O Designation D.D.O. Place of Working D.D.O. Mandal D.D.O. District 1 Sri. S. Gurunadha Rao 7
Head Master

Please verify with experts before submission. For your valuable suggestion please contact Ph.No. 9848363735 (or) ksr_0708@yahoo.co.in

Govt. High School, Begum Bazar Khairthabad

Hyderabad District 7

Date: 22-08-2009 To The Head Master, Govt. High School, Begum Bazar, Khairthabad Mandal, Hyderabad District.

Sir, Sub: Request to sanction the Medical Reimbursement in respect of SRI. G.VENKATESWARLU, School Assistant, ZPHS KAVUR, CHILAKALURIPET Mandal, Hyderabad District - Proposals submitted - Reg.

Ref:

1. G.O. Ms.No. 74, M&H Dept., dated: 15-03-2005. 2. G.O. Ms.No. 105, M&H Dept., dated: 09-04-2007. 3. Medical Bills issued by the Doctor concerned. 4.G.O.Ms.No. 68 HM & FW dated:28/03/2011 -o0o-

With reference to the subject cited, I submit here with the Medical Bills with all the enclosures for Medical Reimbursement for an amount of Rs. 20000=00 (Rupees (Rupees Twenty Thousand and Zero Only) only) as my Daughter named BABY. Y. SARALA who is wholly dependent on me has undergone Treatment for the desease FEVER in the Recognised Hospital by the Andhra Pradesh State Government i.e., at LALITHA SUPERSPECIALITY, GUNTUR during the period from 01-07-2009 to 10-07-2009 and onward transmit to the higher authorities for further necessary action in the matter at an early date.

Thanking You Sir. Yours faithfully, Enclosures: Essentiality Certificate Emergency Certificate Discharge Summary Investigation Report Dependent Certificate Medical Bills Check List ( G.VENKATESWARLU) School Assistant, ZPHS KAVUR, CHILAKALURIPET Mandal, Hyderabad District.

Non-Drawl Certificate

GOVERNMENT OF ANDHRA PRADESH DEPARTMENT OF SCHOOL EDUCATION From The Head Master, Govt. High School, Begum Bazar, Khairthabad Mandal, Hyderabad District. To The District Educational Officer, Hyderabad

Lr. No. __________, Dt: __________ . Respected Madam, Sub: Request to sanction the Medical Reimbursement in respect of SRI. G.VENKATESWARLU, School Assistant, ZPHS KAVUR, CHILAKALURIPET Mandal, Hyderabad District - Proposals submitted - Reg.

Ref: 1. G.O. Ms.No. 74, M&H Dept., dated: 15-03-2005. 2. G.O.Ms.No. 105, M&H Dept., dated: 09-04-2007. 3. Medical Bills issued by the Doctor concerned. 4. Proposals received from the incumbent dated: 22-08-2009 5.G.O.Ms.No. 68 HM & FW dated:28/03/2011 -o0oWith reference to the subject cited, I submit herewith the Medical Bills with all the enclosures submitted by SRI. G.VENKATESWARLU, School Assistant, ZPHS KAVUR, CHILAKALURIPET Mandal, Hyderabad District for your kind sanction of the Medical Reimbursement for an amount of Rs. 20000=00(Rupees (Rupees Twenty Thousand and Zero Only) only) as his Daughter BABY. Y. SARALA who is wholly dependent on him has undergone Treatment for desease FEVER in the Recognised Hospital by the Andhra Pradesh State Government i.e., at LALITHA SUPERSPECIALITY, GUNTUR during the period from 01-07-2009 to 10-07-2009 and onward transmit to the higher authorities for further necessary ction at an early date.

Date of treatment

From From From From

To To To To

Thanking You Madam. Enclosures: Essentiality Certificate Emergency Certificate Discharge Summary Investigation Report Dependent Certificate

Yours faithfully,

Medical Bills Check List Non-Drawl Certificate

NON DRAWL CERTIFICATE (As per instructions issued in C & DSE, A.P., Hyderabad Procs. Rc.No. 8878/D3-4/2009, dated: 02-09-2009)

This is to certify that, the amount of Rs. 20000=00 (Rupees (Rupees Twenty Thousand and Zero Only) only) is being claimed now in this bill by SRI. G.VENKATESWARLU, School Assistant, ZPHS KAVUR, CHILAKALURIPET Mandal, Hyderabad District has not been paid previusly towards Medical Reimbursement in respect of his Daughter named BABY. Y. SARALA age (15) Years who has undergone the Treatment for the desease FEVER during the period from 01-07-2009 to 10-07-2009 in the Recongised Hospital by the Andhra Pradesh State Government i.e., at LALITHA SUPERSPECIALITY, GUNTUR as per the records available regarding the Medical Reimbursement defined under the Government Medical Attendance Rules, 1972

It is Certified that this is the . Spell of the treatment for the disease mentioned. A note to that effect has also been made in the records of the school.

Signature of the Government Servant.

Signature of the Drawing & Disbursing Officer.

CHECK LIST (Vide Rc No.8878/D3-4/2009,Dt.02-09-2009 of C & DSE AP, Hyderabad)

SRI. G.VENKATESWARLU School Assistant
1

Name and Address of the employee Employee code

ZPHS KAVUR, CHILAKALURIPET Mandal, Hyderabad District.

If Retired a)Date/Year of Retirement

2

b)Designation c) P.P.O.NO
School Assistant ZPHS KAVUR, CHILAKALURIPET Mandal, Hyderabad District. cell no. From: From: From: From: 01-07-2009 To: To: To: To: 10-07-2009

Communication of the Applicant Address For all purposes with cell no.

Dates of Treatment

Name and Address of Hospital

a)Whether Private Hospital (or) Recognized Hospital b)Whether referral Letter Produced (or) Recognized orders to be enclosed along with the proposals

LALITHA SUPERSPECIALITY, GUNTUR RECOGNISED YES / YES / YES / YES / NO NO NO NO

Whether the Medical Reimbursement Proposal sent with in 6 Months from the Date of Discharge Whether the Following are Enclosed 1)Appendix-II duly attested by the Head of the office/DDO 2)Emergency Certificate 3)DischargeSummary 4)discharge summary 5) Non drawl Cerficate

YES / YES / the authorized doctor, who

NO NO

6)Essentially certificate, attested by 7 undertakes treatment

YES /

NO

7)If the Patient is dependent on the Govt.Employee-Un Employee crfificate and dependency certificate are to be enclosed with the Medical Reimbursement Proposals 8)In case of the dependents of deceased Govt.Employee/Retired employee whether legal heir certificate in enclosed (or) not. 9)Whether the Medical reimbursement proposal is prepared and submitted with reference to G.O.Ms.No.74 H.M. & FW(K1) Dept. Dt. 1503-2005 and G.O.Ms.No.60 HM &(K1) Dept.Dt 09-04-2007 and also G.O. Ms No 180 dt.11-05-2006. 8 Whether the medical Reimbursement claim is processed throught the drawing officer and received with in the stipulated time.

Not Applicable

9 And whether the availment of No. of Instalments recorded (or) not Whether an entry is Made in the Service Register (or) not for previous claim

Not Applicable

10

Signature of the Government Servant

Signature of the Head of the Office

APPENDIX II
APPLICATION FOR CLAIMING REFUND OF MEDICAL EXPENSES INCURRED IN CONNECTION WITH MEDICAL ATTENDANCE AND TREATMENT OF GOVERNMENT SERVANT AND THEIR FAMILIES 1 Name, Designation & Section of Government Servant (in block letters) SRI. G.VENKATESWARLU SCHOOL ASSISTANT ZPHS KAVUR, 2 Office in which Employed Pay of the Government Servant as defined in F.Rs. and other employments which should be shown separately Place of Duty CHILAKALURIPET Mandal, Hyderabad District. 3 14860-39540 / 14860 ZPHS KAVUR, 4 CHILAKALURIPET Mandal, Hyderabad District. H.No. 16-1-178/A/9, 5 Full Residential Address with door number, name of the Mohalla and District Hari Puri Colony, Hyderabad. PIN - 500072 6 Name of the Patient, his/her relationship to the Government Servant, in case of children state age also Place at which the patient fell ill Baby. Y. Sarala, (Daughter) Aged 15 Years LALITHA SUPERSPECIALITY, GUNTUR

FEVER 8 Nature of illness and its duration From: 01-07-2009 From: From: 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 To: To: To: 10-07-2009

List of Medicines in detailed and Essentiality Certificates are enclosed Rs. 20000=00 and Zero Only)

10 Total amount claimed

(Rupees Twenty Thousand Essentiality Certificate Emergency Certificate Discharge Summary Investigation Report Dependent Certificate Medical Bills Check List Non-Drawl Certificate

11 List of Enclosures

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 upon me.

Signature of the Government Servant

Signature of the Head of the Office

DEPENDENT CERTIFICATE GIVEN BY THE GOVERNMENT SERVANT (As per instructions issued in C & DSE, A.P., Hyderabad Procs. Rc.No. 8878/D3-4/2009, dated: 02-09-2009)

I, SRI. G.VENKATESWARLU, School Assistant, ZPHS KAVUR, CHILAKALURIPET Mandal, Hyderabad District, do hereby declare that, BABY. Y. SARALA, age (15) Years is my Daughter and has no property of income of her own and that, she is wholly dependent on me only, she is also not a Employee or Pensioner

Signature of the Government Servant.

Signature of the Drawing & Disbursing Officer.

DESIGNATION 0 DISTRICT 1 Assistant Director 2 Assistant Engineer 3 Asst. Commissioner for Govt. Exams 4 Asst. Section Officer 5 Asst. Statistical Officer 6 Auditor 7 Cashier 8 Deputy Director 9 Deputy Educational Officer 10 Deputy Inspector of Schools 11 District B.C. Welfare Officer 12 District Educational Officer 13 District Tribal Welfare Officer 14 Divisional Engineer 15 Executive Engineer 16 Gazetted H.M. Gr-I 17 Gazetted H.M. Gr-II 18 Joint Director 19 Junior Assistant 20 Junior Lecturer 21 L.F.L. Head Master 22 L.F.L. Head Mistress 23 Language Pandit 24 Language Pandit (Hindi) 25 Language Pandit (Sanskrit) 26 Language Pandit (Tamil) SCALE OF PAY 27 Language Pandit (Telugu) 28 Language Pandit (Urdu) 29 Mandal Educational Officer 30 Office Subordinate 31 Physical Education Teacher 32 Principal 33 Project Officer 34 R.J.D.S.E. 35 Record Assistant 36 School Assistant 37 School Assistant (Bio. Sc.) 38 School Assistant (English) 39 School Assistant (Hindi) 40 School Assistant (Maths) 41 School Assistant (Phy. Edn.) 42 School Assistant (Phy. Science) 43 School Assistant (Soc. Stu.) 44 School Assistant (Telugu) 45 School Assistant (Urdu) 46 Secondary Grade Teacher 47 Senior Assistant 48 Senior Lecturer 49 Superintendent 0 0 0 0 0 0

0 GENDER 0 0 1 Adilabad District 1 Male 1 2 Ananthapur District 2 Female 2 3 APSR Nellore District 0 0 0 4 Chittoor District OF RESIDENCE TYPE 0 HRA PERCENTAGE 5 East Godavari District Govt. Quarters 1 1 6 Guntur District 2 Own House 2 7 Hyderabad District 3 Rented House 3 8 Kareemnagar District0 0 4 9 Khammam District 0 0 0 10 Krishna District MONTHS 0 C.C.A 11 Kurnool District 1 Not Applicable 1 12 Mahboobnagar District 03/10/10 2 2 13 Medak District 3 04/10/10 3 14 Nalgonda District 4 05/10/10 4 15 Nizamabad District 5 06/10/10 5 16 Prakasham District 6 07/10/10 0 17 Ranga Reddy District 08/10/10 7 0 18 Sreekakulam District8 09/10/10 SURRENDER CLAIMED DAYS 19 Vishakapatnam District 10/10/10 9 0 20 Vizianagaram District 11/10/10 10 1 21 Warangal District 11 12/10/10 2 22 West Godavari District 01/10/11 12 3 23 YSR Kadapa District 13 02/10/11 0 0 0 0 0 0 0 0 0 0 CPS 0 0 0 1 1 6700-20110 0 0 2 2 6900-20680 0 0 0 3 7100-21250 0 0 0 4 7520-22430 0 0 0 5 7740-23040 0 0 0 6 7960-23560 0 0 0 7 8440-24950 0 0 0 8 9200-27000 0 0 0 9 9460-27700 0 0 0 10 10020-29200 0 0 0 11 10900-31550 0 0 0 12 11530-33200 0 0 0 13 11860-34050 0 0 0 14 12550-35800 0 0 0 15 12910-36700 0 0 0 16 13660-38570 0 0 0 17 14860-39540 0 0 0 18 15280-40510 0 0 0 19 16150-42590 0 0 0 20 18030-43630 0 0 0 21 19050-45850 0 0 0 22 20680-46960 0 0 0 23 21820-48160 0 0 0 24 23650-49360 0 0 0 25 25600-50560 0 0 0 26 27000-51760 0 0 0

0 0 1 Father 2 Mother 3 self 4 Legal Hier 5 Husband 6 Wife 7 Son 8 Daughter 9 Widower 10 Nephew 11 Niece 0 DDO Desgn 1 Assistant Director 2 Deputy Director 3 Deputy Educational Officer 4 Deputy Inspector of Schools 5 Gazetted H.M. Gr-I 6 Gazetted H.M. Gr-II 7 Head Master 8 Head Mistress 9 Mandal Educational Officer 10 Principal 11 Project Officer 12 R.J.D.S.E. 0 0 0 0 0 0 Assistant Director 0 Deputy Director 0 Deputy Educational Officer 0 Deputy Inspector of Schools 0 Gazetted H.M. Gr-I 0 Gazetted H.M. Gr-II 0 Head Master 0 Head Mistress 0 Mandal Educational Officer 0 Principal 0 Project Officer 0 R.J.D.S.E. 0 0 0 1 Adilabad District 2 Ananthapur District 3 APSR Nellore District 4 Chittoor District 5 East Godavari District 6 Guntur District

0 0

0 0

0 0 0 0 0

0 0 0 Adilabad Ananthapur Nellore Chittoor Kakinada Guntur

27 29200-53060 28 31550-53060 29 34050-54360 30 37600-54360 31 41550-55660 32 44740-55660 0 0 1 Sri. 2 Smt. 3 Kum. 0 0 1 Baby. 2 Kum. 3 Master. 4 Miss. 5 Mrs. 6 Smt. 7 Sri. 0 0 0 0 1 Government 2 Private 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 0 2 0 1 0 1 0 2 0 2 0 2 0 2 0 1 0 2 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 Father he 2 Mother she 3 self he 4 Legal Hier she 5 Husband he 6 Wife she 7 Son he 8 Daughter she 9 Widower she 10 Nephew he 11 Niece she 0 0 0 0 0 0 0 0 1 Father his 2 Mother her 3 self his 4 Legal Hier her 5 Husband his 6 Wife her 7 Son his 8 Daughter her 9 Widower her 10 Nephew his

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0

7 Hyderabad District 8 Kareemnagar District 9 Khammam District 10 Krishna District 11 Kurnool District 12 Mahboobnagar District 13 Medak District 14 Nalgonda District 15 Nizamabad District 16 Prakasham District 17 Ranga Reddy District 18 Sreekakulam District 19 Vishakapatnam District 20 Vizianagaram District 21 Warangal District 22 West Godavari District 23 YSR Kadapa District 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Hyderabad Kareem Nagar Khammam Machilipatnam Kurnool Mahboobnagar Sanga Reddy Nalgonda Nizamabad Ongole Hyderabad Sreekakulam Vishakapatnam Vizianagaram Warangal Elure Kadapa 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

11 Niece 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

her 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0

0 BASIC PAY 1 2 0 3 0 4 10 5 12.5 6 20 7 30 8 0 9 0 10 Not Applicable 11 GHMC 12 GVMC 13 Vijayawada 14 Other MC 15 0 16 0 17 0 18 0 19 Not Applicable 20 15 21 30 22 0 23 0 24 0 25 Yes 26 No 27 0 28 0 29 0 30 0 31 0 32 0 33 0 34 0 35 0 36 0 37 0 38 0 39 0 40 0 41 0 42 0 43 0 44 0 45 0 46 0 47 0 48 0 49 0 50 0 51 0 52 Yes No

0 6700 6900 7100 7300 7520 7740 7960 8200 8440 8680 8940 9200 9460 9740 10020 10300 10600 10900 11200 11530 11860 12190 12550 12910 13270 13660 14050 14440 14860 15280 15700 16150 16600 17050 17540 18030 18520 19050 19580 20110 20680 21250 21820 22430 23040 23650 24300 24950 25600 26300 27000 27700

0 LIST OF RECOGNISED HOSPITALS 0 0 0 0 0 0 1 A.P. Super Speciality0Dental Hospital PVT Ltd, Road No. 2, Banjara H Emp Res 0 Name of the Employee 0 2 Aditya Hospital, 4-1-16, Boggulakunta, Tilak Road, Abids, Hyderabad. 0 Sri. G.VENKATESWARLU Sri. G.VENKATESWARL 0 3 Alpha Hospital, 23-1-863, Near MCH Swimmingpool, Moghalpura, Hyd 0 0 0 0 0 4 Amaravathi Institute of Medical Science Pvt. Ltd., Kothapet, Guntur 0 0 0 0 0 5 Ameerpet Superspeciality Dental Hospital &0Implant Centre, 102 Class 0 0 0 0 6 American Institute of 0 Dentistry, Besides Chermas 8-3-944/12/4, Ameer 0 0 Name of the Patient 0 7 Andhra Hospitals, CVR Complex, Y. Sarala Road, Vijayawada 0 Baby. Prakasam Baby. Y. Sarala 0 8 Ankith Multi Specialty Hospital, Ibrahim Patnam, R.R. Dist. 0 0 0 0 0 9 Apollo DRDO Hospital, Kanchanbagh, Secunderabad. 0 0 0 0 0 10 Apollo Hospital, Jublee Hills, Hyderabad 0 0 0 0 0 11 Apollo Hospital, Vikrampuri, Secunderabad.0 Name of the DDO 0 0 0 12 Apollo Hospital, Waltair Mainroad,S. Gurunadha Rao 0 Sri. Visakhapatnam Gurunadha Rao Sri. S. 0 13 Apollo Hospitals, D.No. 13-1-13,0 0 Main Road, Kakinada.0 0 0 14 Aravind Kidney Centre, 15/402, Brindavanam, Main Road, Nellore. 0 Sir 0 0 0 15 Aravind Nethralaya Meenakshi Diabetes and Endocrinology and Supe 0 0 0 0 0 16 ARK Hospital, Kukatpally, Hyderabad. 0 0 0 ENCLOSURES 0 17 Arun Kidney Center, 0 29-23-9, Tadepallivari 0 Essentiality Certificate 0 Street, Suryaraopet, Vijaya 0 18 Asha Hospitals, Court Road, Anantapur. 0 Emergency Certificate 0 0 0 19 Asian Institute of Gastroenterology, Somajiguda, Hyderabad 0 0 0 Discharge Summary 0 20 Aswini Dental Hospital, 143-A Block, Aditya0 Investigation Saradhi Stu 0 0 Enclave, opp. Report 0 21 Aswini Hospital, Near RTC Bus Stand Mangalagiri Road, Certificate 0 0 0 Dependent Guntur 0 22 Baba Dental Clinic, 2nd Floor, Mediworld, 14-37-39, Maharanipet, Visa 0 0 0 Medical Bills 0 23 Bhimavaram Hospital, J.P. Road, Bhimavaram. 0 0 0 Checklist 0 24 Bollineni Eye Hospital and Research Center, Non-Drawl Certificate 0 0 0 Dargametta, Nellore. 0 25 Bollineni Heart Centre, 46-7-47, 0 0 Danavaipet, Rajhmundry. 0 SUM 0 26 Bollineni Ramanaiah 0 Memorial Hospital, Ambuja Centre, Durgamitta, N 0 0 0 0 27 Care Hospital (A unit0 Quality care India Ltd), Banjara0Hills, Hyderaba of 0 0 0 28 Care Hospital (Quality Care Inida Limited) Exhibition Road, Nampally, 0 0 0 0 0 29 Care Hospital, Waltair Main Road, Visakhapatnam 0 0 0 0 0 30 Chaitanya Dental Hospital, 1-1-230/33 Jyothi Bhavan, Chikkadpally, H 0 0 0 0 0 31 Challa Hospital, 7-1-71/A/1, Dharam Karan 0 0 0 Road, Ameerpet, Hyderaba 0 0 32 Charitasri Hospitals Ltd., 29-6-8/1, Ramachandra Rao Road, Suryarao 0 0 0 0 0 33 City Cardiac Research Center Ltd, Ring Road, Near ITI0College, Vijyaw 0 0 0 0 34 City Super Speciality0 Dental Hospital, Shobha Pavani Complex, 1 st Fl 0 0 0 0 35 Dental Venue Multi Speciality Hospital, F-14, First Floor, Deepthi Apar 0 0 0 0 0 36 Diacon Diabetes Specialty Centre & Diagnostics, VV's Vintage Boulava 0 0 0 0 0 37 Dilsuknagar Superspeciality Dental Hospital, Sirigiri Complex, Dilsulkn 0 0 0 0 0 38 Dr. Gowds Dental Hospitals, #19, Durga Enclave, Road No.12, Banjar 0 0 0 0 0 39 Dr. J.S.R. Dental Health Speciality, 1-128, Surya Towers, Bhavani Nag 0 0 0 0 0 40 Dr. Sridhar International Dental Hospital & Research Center, Eluru Roa 0 0 0 0 0 41 E.N.T. Nursing Home, Bhagathsingh Statu Center, Kothapet, Guntur 0 0 0 0 0 42 FMS Dental Hospital, Aiyangar Plaza, Bank0 0 0 Street, Koti, Hyderbad 0 0 43 Frontier Lifeline (Pvt.0 Ltd.), Chennai 0 0 0 0 44 Geeta Mutli Speciality Hospital, 0 0 Seceunderabad. 0 0 0 45 Global Hospitals ( Aunit of Ravindranath GE Medical Association Pvt. L 0 0 0 0 0 46 Global Hospitals, Banjara Hills, Hyderabad 0 0 0 0 0 47 Global Meidcal Centre (A unit of 0 0 Andhra Helath Diagnositc Services Lt 0 0 0 48 Gowri Gopal Hospitals Pvt. Ltd., 0 0 Kurnool 0 0 0 49 GSL General Hospital, NH-5, Lakshmi Puram, Rajhmundry. 0 0 0 0 0 50 GVR Childrens Hospital, 43/48, 2nd Lane, N.R.Pet, Kurnool - 518004. 0 0 0 0 0 51 Harini Gastro & Liver0 Centre, 29-14-51, Prakasam Road, Suryaraopet, 0 0 0 0 52 Health Hospitals Prakasam Road, Tenali - 522201,Guntur District. 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 she 0 0 0 0 0 0 0 0 0 0 0 0 0 0 her 0 0 0 0 0 0 0 0 0

53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 75 76 77 78 79 80 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

28450 29200 29950 30750 31550 32350 33200 34050 34900 35800 36700 37600 38570 39540 40510 41550 49360 50560 51760 53060 54360 55660 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

53 Heart Care Centre, Dornakal Raod, Near Andhra Bank, Suryaraopet, V 0 0 0 0 54 Help Hospital, MG Road, Vijayawada 0 0 0 0 55 Heritage Hospital, 6-3-907/2, Somajiguda, Hyderabad 0 0 0 0 56 Hope Childrens Hospital, 5-9-24/81, Lake Hills Road, Basheerbagh, H 0 0 0 0 57 Hyderabad Kidney & 0 Laproscopic Centre, Judges Colony,Malakpet, Hy 0 0 0 58 Image Hospital ( Image Health CareLimited)Ameerpet, 0 0 0 0 Hyderabad 59 Indo- American Cancer Institute 0 Research Centre, Banjara Hills, Hyd 0 & 0 0 60 Jaya Hospitals, Chowrastha, Hanamkonda, 0 0 0 Warangal 0 61 Kalyani Dental Hospital Dentistry & Implant 0 0 0 Centre, Opp. Green Park H 0 62 Kamineni Hospitals, L.B.Nagar, Hyderabad 0 0 0 0 63 Karumuri Hospitals, Old Club Road, Guntur 0 522001. 0 0 0 64 Kinnera Super Speciality Hospital, Wyra Road, Khammam 0 0 0 0 65 KNM Smile Dental Hospital, 104, Sai Towers, Beside Kalaniketan, Mai 0 0 0 0 66 Konaseema Institute 0 Medical 0 of Sciences, NH - 214, Chaitanya Nagar, 0 0 67 Krishna Children's Hospital, (A unit Ashwik Hospital Pvt Ltd), Niloufer H 0 0 0 0 68 Krishna Institute of Medical Sceinces, Minister Road, Begumpet, Hyde 0 0 0 0 69 Kurnool Heart & Brain Centre, 43-1-1-K-B-4, Sapthagiri0Nagar, A-Cam 0 0 0 70 L.K. Hospitals Pvt. Ltd., 4-159 & 0 0 4-172, Maruthi Nagar,0 0 Malkajgiri, Ran 71 Lalitha Superspeciality Hospital Heart & Brain Centre, Gowrisankar Th 0 0 0 0 72 Lazarus Hospital, Waltair main road, Visakhapatnam 0 0 0 0 73 Life Hospitals (a Unit0 Sai Balaji Health Care) Shivam0Road, D.D. Co of 0 0 74 Life Kare Dental Hospital, 9-7-83/1, Sri Laxmi Complex, Maruthi Nagar 0 0 0 0 75 Life Line Hospitals, 2-4-152, Ram Nagar, Hanmakonda, Warangal Dist 0 0 0 0 76 Lions District 324-C1, Cancer Treatment & Research Centre, Seetham 0 0 0 0 77 Lotus Children's Hospital, Lakdika Pool, Hyderabad. 0 0 0 0 78 M.S. Multi Speciality 0 Dental Hospital, 8-2-165/8, Wyra Road, Khamma 0 0 0 79 Madhava Nursing Home, 43, Sarojini Devi Road, Secunderabad. 0 0 0 0 80 Mamatha General Hospital, 5-7-200, Giri Prasad Nagar, Urban Manda 0 0 0 0 81 Maxivision Laser Centre Pvt. Ltd., Begumpet, Hyderabad 0 0 0 0 82 Mediciti Hospital, 5-9-22, Secretariat Raod, 0 0 0 Sarovar Complex, Hyderab 0 83 Medwin General Hospital, Mankamma Thota, Karimnagar. 0 0 0 0 84 Medwin Hospital, Chirag Ali Lane, Hyderabad 0 0 0 0 85 Meena Hospital, Sai 0 Ranga Towers, Thukaram Gate, North Lallaguda, 0 0 0 86 MNR Medical College & Hospital, Fasalwadi, Sangareddy, Medak Dist 0 0 0 0 87 Modern Eye Hospital, & Research Centre 16-11-101, Beside Venkatar 0 0 0 0 88 MVS Accident Hospital, Suryaraopet, Vijayawada 0 0 0 0 89 Mythri Multi Speciality Hospitals,0Ameerpet,0 0 Hyderabad0 90 N. N. Speciality Dental Hospital, 0 0 N.H. 7, Tirumala Theatre Road, Nirma 0 0 91 Nagarjuna Hospitals,Kanuru, Vijayawada-7 0 0 0 0 92 Narayana Medical College and Hospital, Chinta Reddy0 0 0 0 Palem, Nellore 93 Navata Multi Speciality Dental Care Center,0 0 0 5-6-224, Saraswathi Naga 0 94 Naveen Dental Hospital, 151-A, 0 Ram Street, Tirupthi. 0 Sri 0 0 95 Navya Nethralaya 2-2-349, K.V. 0 0 Layout, (Near LIC Office) Tirupathi 0 0 96 New Life Hospital, Kamal Theatre Complex,0Chaderghat, Hyderabad. 0 0 0 97 Nightingale Hospital, 0 17-1-383/N.S/3 & 4, Opp. Amber 0 0 0 Biscult Factory, 98 NRI General Hospital, Chinakakani, Guntur 0 0 0 District. 0 99 Padma Chandra Super Specialty Hospital, Budhawarpet, Kurnool. 0 0 0 0 100 Partha Dental Hospital & Research Centre, 0Rama Talkies Circle , Visk 0 0 0 101 Partha Dental Hospital & Research Centre, 0 0 0 600/44/77, 0 P.K. Layout,Tir 102 Pinamaneni Care Hospital, Siddhartha Nagar, Vijayawada 0 0 0 0 103 Poulomi Hospital, Rukminipuri Colony, Dr. A.S. Rao Nagar, Main Road 0 0 0 0 104 Pragna Children's Hospital, 6-3-347/22/B/1,0 0 0 Dwarkapuri Colony, Near 0 105 Premier Hospital, Masab tank, Humayun Nagar, Mehdipatnam, Hydera 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

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106 Purna Heart Institute 0 0 0 0 Kovelamudivari Street, Suryaraopet,Vijayawada 107 R.K. Super Speciality Dental Hospital, Andhra Bank Complex, Kothape 0 0 0 0 108 Rainbow Children Hospital,Banjara Hills, Hyderabad 0 0 0 0 109 Raju Neuro & Multispeciality Hospital,and Raju Emergency Hospital, 7 0 0 0 0 110 Ram Hospital, Shapur Nagar, IDA Jeedimetla, Hyderabad-500055 0 0 0 0 111 Ravi Institute of Child Health (RICH Hospitals) 16-11/131, Kasturidevi 0 0 0 0 112 Remedy Heart Institute (A unit of Remedy Hospital Ltd.), Opp. TTD, Hi 0 0 0 0 113 Remedy Hospitals, Ferozguda, Balanagar, Hyderabad.0 0 0 0 114 Remedy Hospitals, Road No.4, KPHB Colony Kukatpally, Hyderabad 0 0 0 0 115 Rohini Medicare (Pvt.) Limited, Subedari, Hanamkonda - 506 001, Wa 0 0 0 0 116 Royal Hospitals, 33-25-45, Kasturi Bai Pet, 0 0 0 Vijayawada0 117 Rukku's save-in-smile Cosmetic 0 0 and Dental0 specilaity Hospital, Barkat 0 118 Sai Bhavani Super Specialty Hospital, Main0 0 0 Road, Shapur Nagar, Jeed 0 119 Sai Care Hospital, Ambadkar Statue, Hanumakonda, Warangal 0 0 0 0 120 Sai Krishna Super Speciality Neuro & Trauma Hospital, Kachiguda, Hy 0 0 0 0 121 Sai Vani Hospital (A Unit of Lakshmi Jaya Hospitals Ltd., Opp. Indira P 0 0 0 0 122 Sai Venkata Sai Medical College& Hospital,0Yenugonda, Mahabubnag 0 0 0 123 Sanjana Palamoor Nursing Home, D.No. 8-6-257/7, Padmavathi Colon 0 0 0 0 124 Sankar Foundation Eye Hospital, D.No. 16-152, Srinivasa Nagar, Simh 0 0 0 0 125 Satya Kidney Centre, Street No.4, Himayathnagar, Hyderabad. 0 0 0 0 126 Seven Hills Hospital, 0 0 0 0 Rockdale Layout, Visakhapatanam 127 Sharat Laser Eye Hospital, D.No. 3-1-119, Kakatiya Colony, Alankar C 0 0 0 0 128 Shravana Hospitals, 0 5-3-847, Mozamjahi Market, Hyderabad 0 0 0 129 Sibar Charitable Trust (Cancer Hospital), Governorpet,Vijayawada 0 0 0 0 130 Sigma Hospital, (A Unit of D.B.R0Hospital Pvt. Ltd.,35,S.D. Road, Secu 0 0 0 131 Siri Dental Clinic, Narayanaguda, Hyd. 0 0 0 0 132 Smiline Dental Hospital, Main Road, Ameerpet, Hyderabad 0 0 0 0 133 Smt. Bhagwan Devi Hospital, 21-7-191, Mama Jumla Pathak Charkam 0 0 0 0 134 Soumya Multi Speciality Hospital, Karkhana, Secunderabad 0 0 0 0 135 Sri Devi Eye Hospital, 29-6-13A,0Nakkal Road, Suryaraopet, Vijayawad 0 0 0 136 Sri Sai Hospitals, 5/2, Arundalpet, Guntur - 522002 0 0 0 0 137 Sri Sai Kidney Center, (A Unit of0 0 Twin Cities Kidney Center Pvt Ltd.), 7 0 0 138 Sri Vijaya Durga Cardiac Centre0 0 46-728-C, 0 Budhawarpet, Kurnool 0 139 Sridhar Super Speciality Dental Hospital, Opp. Gold Spot, Ameerpet, H 0 0 0 0 140 St. Ann's Hospital, Fathimanagar, Kazipet, Warangal 0 0 0 0 141 SVR Neuro Hospital ( Aunit of SVR Neuro & Trauma Super Speciality 0 0 0 0 142 SVS Dental Hospital,0Opp. Bata 0 R.P. Road,0Seceunderabad. 0 143 Swatantra Hospitals (Multi Specialities) Pvt.0 0 0 Ltd. Near Kambala Park, R 0 144 Udai Clinic Orthopedic Center, Chappal Road, Hyderabad. 0 0 0 0 145 Usha Cardiac Centre, Labbipet, 0 0 M.G.Road, 0 Vijayawada. 0 146 Usha Mullapudi Cardiac Centre, 0 0 Gajularamaram, Qutubullahpur Munic 0 0 147 Vamshi Multispciality0 Dental Hospital, 102-104, Ist Floor, Agraj Plaza, 0 0 0 148 Vasavi ENT & Cancer Institute, 6-1-91, Opp. Meera Theatre, Lakdikap 0 0 0 0 149 Vasvi Eye Hospital, 5-7-17, Khaleelwadi, Nizamabad. 0 0 0 0 150 Vijaya Eye Hospital, 5-8-104, Lakshimpuram, Guntur 0 0 0 0 151 Vijaya Health Care Centre,8-2- 86,Kumariguda, Near Passport office, S 0 0 0 0 152 Vijaya Super Speciality Dental Hospital, opp. Rama Talkies, C.B.M. Co 0 0 0 0 153 Vijetha Hospital (A unit of Vijetha Helath Care and Research Centre Pv 0 0 0 0 154 Viswa Bharati Super 0 Speciality Hospital, Gayatri Estates, Kurnool 0 0 0 155 Wockhardt Hospitals, 4-1-1227, 0 0 King Koti Road, Abids,0Hyderabad 5 0 156 Woodlands Hospital, 0 Barkatpura, Hyderabad 0 0 0 157 Yashoda Hospital, Secunderabad 0 0 0 0 158 Yashoda Suepr Speciality Hospital, Malakpet, Hyderabad 0 0 0 0

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159 Yashoda Super Speciality Hospital, Somajiguda, Hyderabad 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 Designation Place of working Mandal District Scale of Pay Basic Pay Add1 Add2 Add3 Add4 School Assistant KAVUR ZPHS CHILAKALURIPET Mandal Hyderabad 14860-39540 14860 H.No. 16-1-178/A/9 Colony District Hari Puri Hyderabad PIN - 500072 0 0 0 Hyderabad14860-39540 / 14860 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Relationship with Emp Name of the Hospital Amount in Figures in Words Joining of Discharge submission of Proposal to DD Age of Patient Name of the Treatment Amount Date of Date Date of 0 Daughter 15 Years LALITHA SUPERSPECIALITY, GUNTUR Twenty Thousand and Zero Only) Fever 20000 (Rupees 07/01/09 07/10/09 08/22/09 0 0 15 Category of Hospital 0 0 0 0 0 0 0 0 0 Private 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Designation Place of working Mandal District 0 0 he 0 0 0 Head Master Govt. High Khairthabad Mandal District 0 School, Begum Bazar Hyderabad 0 his him 20000=00 from 01-07-2009 to 10-07 2 0 1 0 0 With reference to the subject cited, I submit herewith the Me 0 0 0 0 The Head Master, The Head Master, The DistrictThe Commissioner &0Director of0 Educational Officer,Govt. High School, BegumHyderabad District, 0 Khairthabad Mandal, 0 Bazar, Hyderabad District.Khairthabad Prades 0 School Education,0Andhra Manda Hy 0 0 0 0 0 20000=00(Rupees (Rupees Twenty Thousand and Zero Only) only 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 Essentiality Certificate 0 0 0 0 0 0 0 2 Emergency Certificate 0 0 With reference to the subject cited, I submit herewith the Me 0 0 0 0 2 Discharge Summary 0 0 0 0 0 0 0 2 Investigation Report 0 0 0 0 0 0 0 2 Dependent Certificate 0 0 0 0 0 0 0 2 Medical Bills 0 0 0 0 0 0 0 2 Check List 0 0 0 0 0 0 0 2 Non-Drawl Certificate 0 0 0 0 0 0 0 16 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 DEPENDENT CERTIFICATE 0 0 0 0 0 0 0 0 0 I, SRI. G.VENKATESWARLU, School Assistant, ZPHS KA 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

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PIN - 500072

from 01-07-2009 to 10-07-2009