MEDICAL REIMBURSEMENT BILL INSTRUCTIONS 1. Go to DATA Sheet 2. find the fallowing heads and enter the data in the relavant fields a 1.DATA OF THE EMPLOYEE FOR MEDICAL REIMBURSEMENT BILL PROPOSALS II.PERTICULARS FOR BILL CLAIM AFTER SANCTIONING THE AMOUNT BY AU 3. For midical reimbursement bill proposals enter the data in the 1st hea print the sheets in the order 1.proceed , 2.CHECKLIST ,3.CHECKLI 4. After the proposals are accepted and the sanctioning of the bill ,ente 5. submit the bills to the treasury [email protected]www.apteachers.blogspot.
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MEDICAL REIMBURSEMENT BILL PREPARATION
INSTRUCTIONS
1. Go to DATA Sheet
2. find the fallowing heads and enter the data in the relavant fields and select SAVEAS option and save the file with your name
1.DATA OF THE EMPLOYEE FOR MEDICAL REIMBURSEMENT BILL PROPOSALS
II.PERTICULARS FOR BILL CLAIM AFTER SANCTIONING THE AMOUNT BY AUTHORITIES
3. For midical reimbursement bill proposals enter the data in the 1st head
print the sheets in the order 1.proceed , 2.CHECKLIST ,3.CHECKLIST2,4.APPENDIX 5.APPLICATION FORM, 6,NON DRAWL -DEPENDENT CERITFCATE
4. After the proposals are accepted and the sanctioning of the bill ,enter the data under 2nd head and print the sheets from " f58" to "back47" sheets
I here by declare that the statement in this application are true to the best of my knowledge and that The person
for whom medical expenses were incurred is a member of my family as defined in API Medical Attendence
Rules.He/She is dependent on me.Certified that my dependent is not a Govt.Employee.
SIGNATURE OF THE GOVT. EMPLOYEE/PENSIONER AND THE OFFICE TO WHICH HE IS ATTACHED
CHECK SLIP FOR SENDING MEDICAL REIMBURSEMENT PROPOSALS
S.NO
1 Name and Official Address of the Teacher
Y.Gangi Reddy
S.G.T
MPUP SCHOOL CHADULLA
SINGANAMALA M.P , Anantapur .Dt
2 Dates of Treatments From 10-10-09 to 20-10-09
3 Name and Address of the Hospital
4 Whether Private or Government Referal
5
6
7
8
9
10 Whether the Discharge summary of the patient is enclosed ?
11
12
Drawing and Disbursing Officer
Dentocare Super Speciality Hospital, Anantapur
Whether the proposal is received in the head Office within a period of six months from the date of discharge ?
Whether Appendix - II attested by the Head of the Office is enclosed ?
In case of treatment at Recognised Hospital / NIMS / SVIMS whether Emergency certificate is enclosed ?
Whether Essentiality certificate mentioning the amount of expenditure for the treatment, signed by the Doctor who treated and attested by the Authorised Medical Agency is enclosed ?
Whether the Bills for the amount mentioned in the Essentiality certificate , signed by the Doctor , who treated and attested by the Authorised Medical Agency is enclosed ?
In case of retired Govt Employe / Teacher, whether the copy of the pension payment order is enclosed ?
Incase of dependents above the age of 19 years unemployement and Dependency Certtificate,counter signed by the Head of Office is enclosed ?
Indicate 'YES' or 'NO' in the brackets against each item
1
2
3
4
5
6
7
8 All the cash reciepts are with in the period of treatment
9
10
11
12
13
Drawing and Disbursing Officer
CHECK SLIP TO BE SIGNED AND FURNISHED BY THE GOVT.EMPLOYEES
All the columns of the Application form have been filled in properly
The bill has been submitted along with Essentiality Certficate "A" for the treatment as out-patient by furnishing all the particulars and signed by the Medical Attendent who treated the patient
The bill has been submitted along with Essentiality Certficate "B" for the treatment as Int-patient by furnishing all the particulars and signed by the Medical Attendent who treated the patient and counter signed by the Head of the Hospital
The name of the disease has been indicated in the Essentiality certificate in Block letters
The period of treatment has been indicated in the Essentiality certificate
The case Doctor has signed on the Essentiality certificate and counter signed by the Head of the Hospital
All the columns of theEssentiality certificates 'A' , 'B' have been filled in properly
The cash reciepts have been counter signed by the Doctor who treated the patient
The name of the patient and the name of the Doctor has been indicated in all the cash receipts
All the cash reciepts enclosed to the Medical reimbursement claim are dated
The total amount of cash receipt tallied with the amount claimed
The Duplicate bill with the copies of the original bills has been submitted
SRINIVAS GANDHAMANEN I - 99594 22002 - 94402 69989
(MEDICAL REIMBURSEMENT)
Indicate 'YES' or 'NO' in the brackets against each item
Sign of the Employee
CHECK SLIP TO BE SIGNED AND FURNISHED BY THE GOVT.EMPLOYEES
SRINIVAS GANDHAMANEN I - 99594 22002 - 94402 69989
APPENDIX -II (MEDICAL REIMBURSEMENT)
1 Name,Designation & SectionY.Gangi Reddy
S.G.T EDN SECTIOM
2 Office in which Employed MPUP SCHOOL CHADULLA
SINGANAMALA M.P , Anantapur .Dt
3
PAY DA HRA CCA IR O/A
7970 4805 797 80 1753 300
Rs 5750--13030
4 Place of Duty
5 Full Residential Address with Door No D.No.12/153,Cental Excise Colony,Sai Nagar,Anantapur
6 smt resma wife of Y.Gangi Reddy
7 Place at which the Patient fell ill Residence
8 Nature of the illness and its Duration From 10-10-09 to 20-10-09
( copy enclosed )
9
Rs 8660/-
Essentiality Certificates and Bills Enclosed here with
10 Total amount claimedRs 8660
#VALUE!
11 List of enclosures
1 Hospital Reports 5 Emergency Certificate
2 Essentiality Cert 6 Discharge Summary
3 Non Drawl Certfi 7 Check list
4 All Medical Bills 8 Dependence Certificate
( All Originals in Duplicate Submitted )
DECLARATION TO SIGNED BY THE GOVERNMENT EMPLOYEE
M.E.O
APPLICATION FOR CLAIMING REFUND OF MEDICAL EXPENSES INCURRED IN CONNECTION WITH MEDICAL ATTENDENCE AND / OR TREATMENT OF GOVERNMENT EMPLOYEE AND THEIR FAMILES
Pay of the Govt.Servent as defined Which should be shown separately
Name of the Patient and his / her relation ship to the Govt Servent ( In the case of children, state Age also)
Details of amount claimed ,cost of Medicines purchased from the market / list of Medicines , Cash memos, and the Essentiality Certficate should be attached.Each in duplicate signed by treatment Doctor
I here by declare that the statement in this application are true to the best of my knowledge and that The
person for whom medical expenses were incurred is a member of my family as defined in API Medical
Attendence Rules.He/She is dependent on me.Certified that my dependent is not a Govt.Employee.
SIGNATURE OF THE GOVT. SERVENT/PENSIONER AND THE OFFICE TO WHICH HE IS ATTACHED
Essentiality Certificates and Bills Enclosed here with
#VALUE!
Emergency Certificate
Discharge Summary
Dependence Certificate
( All Originals in Duplicate Submitted )
DECLARATION TO SIGNED BY THE GOVERNMENT EMPLOYEE
APPLICATION FOR CLAIMING REFUND OF MEDICAL EXPENSES INCURRED IN CONNECTION WITH MEDICAL ATTENDENCE AND / OR TREATMENT OF GOVERNMENT EMPLOYEE AND THEIR FAMILES
This is to certify that the amount climed in this bill was not drawn and paid previously
Total Amount Rs : 8660.00
( eight thousand six hundred and sixty only )
f¸ñ VÉʪ Clû¼O¸±¼
sfÇÝd³ £¶¢±¸vÀ1. 2008
±µÃ :
±µÃ :
±µÃ :
1.Budget provided for the year
2.Expenditure including this bill
3.Balance
f¸ñ VÉʪ Clû¼O¸±¼
COÓAdÉAdÀ Y¶m±µvÀ O¸±¸ïv±ÀµÀ G¶¶p±ÀÇÃS¸±µèA
No.& Description ofSub - Voucher
Details of expenditure and authority for sanction, drawal of amount
Medical reimbursment bill of smt resma w/o Sri Y.Gangi Reddy, S.G.T, MPUP SCHOOL, CHADULLA, SINGANAMALA Anantapur .Dt as per Prog R.C.No.5601/B5/2007 , dated 30-12-99 of the DIST.EDUCATIONAL OFFICER, ANANTAPUR.
Medical reimbursment bill of smt resma w/o, Sri Y.Gangi Reddy, S.G.T, MPUP SCHOOL, CHADULLA, SINGANAMALA , Anantapur .Dt.
ANNEXURE - IIIGOVT.BANK REPORT
TO BE GENERATED BY TREASURY OFFICE
Treasury Code: 80 Treasury Office Name : DTO ,ANANTAPUR
Govt. Bank Code: 80 Govt, Bank Name: SBI ,B.K.SAMUDRAM
S.No DDO Account Number Purpose
1 123456 ,
Total
( eight thousand six hundred and sixty only )
Signature of the Signature of the Bank Officer Treasury Officer(With Seal) (With Seal)
ANNEXURE - IIIGOVT.BANK REPORT
TO BE GENERATED BY TREASURY OFFICE
Treasury Code: 80 Treasury Office Name : DTO ,ANANTAPUR
Govt. Bank Code: 80 Govt, Bank Name: SBI ,B.K.SAMUDRAM
S.No DDO Account Number Purpose
1 123456 ,
Total
( eight thousand six hundred and sixty only )
Signature of the Signature of the Bank Officer Treasury Officer(With Seal) (With Seal)
Name & Code of N L B
Medical reimbursment bill of smt resma w/o Sri Y.Gangi Reddy, S.G.T, MPUP SCHOOL, CHADULLA, SINGANAMALA Anantapur .Dt.
Name & Code of N L B
Medical reimbursment bill of smt resma w/o Sri Y.Gangi Reddy, S.G.T,
MPUP SCHOOL, CHADULLA, SINGANAMALA Anantapur .Dt.
ANNEXURE - IIIGOVT.BANK REPORT
TO BE GENERATED BY TREASURY OFFICE
DTO ,ANANTAPUR
SBI ,B.K.SAMUDRAM
8,660
8,660
Signature of the Treasury Officer
(With Seal)
ANNEXURE - IIIGOVT.BANK REPORT
TO BE GENERATED BY TREASURY OFFICE
DTO ,ANANTAPUR
SBI ,B.K.SAMUDRAM
8660
8660
Signature of the Treasury Officer
(With Seal)
Amount to be Credited
Amount to be Credited
ANDHRA PRADESH GOVERNMENT
(PAPER TOKEN)
STO Code: 1 0 0 1 (For Treasury Use Only)
Date :DTO/STO Name: Anantapur
Trans ID:DDO Code: 1003567-0092
DDO Designation : M.E.OM.P.P
M.P.SINGANAMALA
Bank Branch Code: 80 BANK Name: SBI
B.K.SAMUDRAM
Head of Account 2 2 0 2 0 1 1 0 3
(Major Head) (Sub - MH) (Major Head) (Grp - SH)
0 5 0 1 0 0 1 7
(Sub Head) (Det. Head) (Sub - Det. Head)
N V 2 2 0 2
Gross Rs. 8660.00 Deducation Rs. Nill Net Rs. 8660.00
( eight thousand six hundred and sixty only )
Messenger Name Designation
2
DDO Signature Attested STO Signature
DDO Signature
DDO Office Name:
Non - Plan = NPlan =P:
Charged = C Voted = V:
Contingency Fund MH/Service Major Head
(As in APTC From - (101)
Specimen Signature of Messenge
1.
D D O Seal
TreasurySeal
APTC FORM 101
(See Subsidiary Rull 2 (W) Under Treasury Rule 15
Govt. Memo No :38907 / Accounts / 65-5, Dt 21.02.1993)
DDO Code 1003567-0092 Treasury/PAO Code 1 0 0 1
M.E.O Treasury/PAO Name: DTO ,ANANTAPUR
To
The Treasury Officer/Manager
SBI
B.K.SAMUDRAM
Please Pay Bill No dated for Rs 8660
( eight thousand six hundred and sixty only )
to Smt/ Sri
whose specimen Signature is attensted herewith.
Signature of the Govt. Servant Received the payment
Dated : Dated
Attested
Signature of the D D O Signature of the Govt.
Servant receiving the
Payment
DDO Designation
D D O Seal
ESSENTIALITY CERTIFICATE CERTIFICATE "A"
(To be completed in the case of patients who are not admitted to Hospital for treatment)
#REF!
I , DR.M.Venkata Krishna Murthy here by certifiy :-
a) That I charged and received Rs 100 for consulting at my room/at patient residence
b) That I charged and received Rs for administering
Intra venous/mascular /sub-cutaneous Injection on at my
consulting room/at patient residence
c) That the injections administered was/were not for immunizing or prophylactic purpose
d)
Name of medicines Price
e) That the patient is/was suffering from Sever Attrition,Badly decayed teeth
and is /was under treatment from ### to ###
f) That the patient is/was not given pre-natal or post- natal treatment
g)
h) That I refered the patient to Dr for specialist consultation
and that necessary approval of the
(Name of the Chief Admin.Medical Officer of the State as required under the rules was obtained)
i) That the patient did not require Hospitalization
j) That the mixture / ointment /powder entered at serial ( ) undet Certificate (d) could not be
dispensed at the Hospital and the patient was advised to buy it from the market
Date:-
Note:- Certificates not applicable should be struck off.certficate (e) is compulsory and must be filled in by the Medical officer in all cases
That the patient has been under treatment at Dentocare Super Speciality Hospital / my consulting room, and that the undermentioned medicines prescribed by me in thes connection were essential for the recovery / prevention of serious deterioration in the condition of the patient.The medicines are not stocked in Dentocare Super Speciality Hospital for the supply to private patients and do not include proprietary preparations for which cheaper substances of therapeutic value are available not preparations which are primerily foods,toilets or disinfectants
That the X-ray / Laboratory tests / treatment etc.. For which an expenditure of Rs 8660/-( Rupees eight thousand six hundred and sixty only ) was incurred were necessary and were undertaken on my advice at Dentocare Super Speciality Hospital Anantapur
Sign of the AMA/Designtion of the Medical Officer, and Hospital / Dispensary to which attached
GOVT. OF ANDHRA PRADESH
(APTC Form - 47)Payable at D.T.O, Anantapur
Pay Bill for the Month & Year 09 2009 (For Treasury Use Only)