Scribd
Upload
9 views1 page

Appendix II

This document is an application for claiming a refund of medical expenses incurred by a government servant, Smt. N. Nikhitha, for treatment at Vaishnavai Hospital. The total amount claimed is Rs. 49,905, with detailed breakdowns of costs for medicines, nursing, and other charges. The application includes various enclosures such as certificates and medical bills to support the claim.

Uploaded by

surender
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
9 views1 page

Appendix II

This document is an application for claiming a refund of medical expenses incurred by a government servant, Smt. N. Nikhitha, for treatment at Vaishnavai Hospital. The total amount claimed is Rs. 49,905, with detailed breakdowns of costs for medicines, nursing, and other charges. The application includes various enclosures such as certificates and medical bills to support the claim.

Uploaded by

surender
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

APPENDIX-II

APPLICATION FOR CLAIMING REFUND OF MEDICAL EXPENSES INCURRED


CONNECTION ON WITH MEDICAL ATTTENDANCE AND FOR TREATMENT OF
GOVERNMENT SERVANT AND THEIR FAMILIES.

1. Name and designation & section [Link], W/o. Sri [Link] kumar.,[Link]

2. Office in which employed O/o. Executive Engineer,


Irrigation Division No.1, Bodhan
Dist Nizamabad – Telangana
3 . Pay of the Govt. Servant as defined __
in FRs and other employments which
should be shown separately.
4. Place of duty Bodhan

5. Full residential address with door No. [Link].6-47/1/A, Gangasthan-2, Nizamabad-503003.


And name of the Mohalla.

6. Name of the patient him/her relationship Smt [Link],


to the Govt. Servant in case of children State W/[Link] [Link] Kumar.,[Link]
ago also.
7. Place at which the patient fall ill Vaishnavai Hospital,Dwaraka Nagar,Nizamabad

8. Nature of illness and its duration “G2P1L1 WITH TG WITH GDM WITH 1PREV’S
LSCS”
period from 17-05-2024 to 20-05-2024
9. Details of amount claimed cost of Medicines Anaesthesia (Local) - 5200=00
Purchased from the market list of medicines Investigation charges - 5500=00
cash memos, the Essentiality certificate should Nursing & Theatre
be attached Each in duplicate signed by charges - 6500=00
treatment doctors Room Rent (2 days) - 2500=00
Lab testings - 1000=00
Lens Cost - 7810=00
Doctor Charges - 9500=00
Medicine charges - 880=00
Total = 49,905=00

10. Total amount claimed Rs. Rs. 49,905=00 (Rupees Thirty eight thousand
eight hundred and ninety only)
11. Enclosures
1. Genuiness certificate Yes
2. Checklist Yes
3. Essentiality Certificate Yes
4. Discharge summary (Original) Yes
5. Non drawl Certificate Yes
6. Cash Receipt. Yes
7. Declaration Certificate Yes
8. Original Medical bills 1 Set
9. Hospital Break up bill 2 Sets
(Xerox Copies) 1 Set

Declaration to be signed by the


Govt. Employee

I hereby declare that the statement in this application are true to the best of my knowledge and belief
my self treatment under the government Servant Medical attendance rules.

Signature of Government Employee.


And office to which attested.

You might also like