m.r.bill-mandal

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

5. submit the bills to the treasury

[email protected] www.apteachers.blogspot.com

mailto:[email protected]

http://www.apteachers.blogspot.com/

MEDICAL REIMBURSEMENT BILL PREPARATION

2. find the fallowing heads and enter the data in the relavant fields and select SAVEAS option and save the file with your name



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

by

Sreenivas Gandhamaneni

School Asst (Maths)

Govt.High school No.1

Old Town ,Anantapur- 515001

cell :-99594 22002 - 94402 69989www.apteachers.blogspot.com



S.NOPARTICULARS NAME EMP ID BANK A/C

DDO CODE AND A/C NO 1003567-0092 123456

1 NAME OF THE EMPLOYEE Sri Y.Gangi Reddy 11111234567 123456789023 TREASURY OFFICE DIST TREASURY OFFICE DTO

2 NAME OF THE DEPENDENT-AGE smt resma TREASURY PLACE - CODE ANANTAPUR 80

3SELF OR RELATION SHIP WITH EMPLOYEE

wife of w/o SALARY BANK NAME STATE BANK OF INDIA SBI

4 DESIGNATION AND SECTION S.G.T EDN SECTIOM BANK PLACE-CODE B.K.SAMUDRAM

5 SCHOOL/OFFICE MPUP SCHOOL R.C.No.5601/B5/2007

6 PLACE CHADULLA AMOUNT SANCTIONED 8660

7 Mandal SINGANAMALA Mandal MP eight thousand six hundred and sixty only

8 DISTRICT Anantapur .Dt Anantapur

9RESIDENTIAL ADDRES D.No.12/153,Cental Excise Colony,Sai Nagar,Anantapur by

10 Residence Sreenivas Gandhamaneni

11 SUFFERING FROM Sever Attrition,Badly decayed teeth School Asst (Maths)

12 TREATMENT GIVEN Consultation.Root canal treatment,Ceramic crowns Govt.High school No.1

13 DURATION OF TREATMENY 10/10/2009 10/20/2009 Old Town ,Anantapur- 515001

14 HOSPITAL NAME & REGD NO Dentocare Super Speciality Hospital cell :-99594 22002 - 94402 69989

15 PLACE AND TYPE OF HOSPITAL Anantapur Referal

17 DOCTOR NAME-REFERED DOCTOR DR.M.Venkata Krishna Murthy

19 NO of CONSULTATION and FEE RS 1 100

20 HOSPITAL EXPENDITURE RS 8660

21PAY OF THE EMPLOYEEE

BAISC DA HRA CCA IR O/A TOTAL PAY SCALE

22 7970 4805 797 80 1753 300 15705 5750--13030

23 DRAWING OFFICER MANDAL EDUCATIONAL OFFICER M.E.O

24 DDO OFFICE- PLACE MANDAL PRAJA PARISHAD M.P.P M.P.SINGANAMALA

25Sri H.kadirappa B.A,B.Ed


IF ,SELF DO NOT ENTER iN THIS COLOR BOXES

PROCEEDIN RC NO OF BILL SANCTIONING AUTHORITY & DATE

ILLNESS FELT AT RESIDENCE/OTHER PLACE

www.apteachers.blogspot.comRupees eight thousand six hundred and sixty only [email protected]

DRAWING OFFICER NAME & QUALIFICATION


mailto:[email protected]

26

DIST.EDUCATIONAL OFFICER O\O D.E.O ANANTAPURSANCTIONING OFFICER- OFFICE - PLACE

27 PROCEEDINGS RC-NO OF DDO 335/2009/B 11/12/2009

From To,

Sri/Smt H.kadirappa DIST.EDUCATIONAL OFFICERB.A,B.Ed O\O D.E.O

MANDAL EDUCATIONAL OFFICER ANANTAPURM.P.SINGANAMALA

Rc.No:- 335/2009/B Date:- ###

Respected sir,

Sub:-

Ref:- 1).

2).

3).

<<<<<<<<<< 0>>>>>>>>>>

I request you to sanction the Medical Reimburement to the individual as early possible

Thanking you sir

yours faith fullyEnclosers

1 Apendix -II2 Essentiality Certificate3 Non Drawl Certficate4 All Medical Bills5 Emergency Certificate6 Discharge Summary7 Check list8 Dependence Certificate

Srinvas Gandhamaneni - 99594 22002 * 9440269989 "www.apteachers.blogspot.com"

API Medical Attendence Rules-Medical Reimbursement bill of Rs

8660/- pertaining of smt resma w/o Sri Y.Gangi Reddy, S.G.T,

MPUP SCHOOL,CHADULLA, SINGANAMALA Mandal,

Anantapur .Dt -proposals submitted - orders -requested -Regd

G.O.M.S.No.105,HM & FW ,Dated 09-04-07 of Govt of Andhra Pradesh,A.P, Hyderabad

G.O.M.S.No.74,HM & FW ,Dated 15-03-05 of Govt of Andhra Pradesh,A.P, Hyderabad

Application of Sri/Smt Y.Gangi Reddy, S.G.T, MPUP SCHOOL, CHADULLA, SINGANAMALA Mandal, Anantapur .Dt

I submit that the smt resma w/o Sri Y.Gangi Reddy, S.G.T, MPUP SCHOOL,

CHADULLA, SINGANAMALA Mandal, Anantapur .Dt, Was under gone the treatment with

Consultation.Root canal treatment,Ceramic crowns, at Dentocare Super Speciality Hospital

Anantapur, from 10-10-09 to 20-10-09 and spent an amount of Rs 8660/- ( Rupees eight thousand

six hundred and sixty only ) for the treatment and requested for Medical Reimbursement

Hence I am here with submitting the Medical Reimbursement Proposals in respect of smt

resma w/o Sri Y.Gangi Reddy, S.G.T, MPUP SCHOOL, CHADULLA, SINGANAMALA Mandal,

Anantapur .Dt with all fullfill requirements for payment

(MEDICAL REIMBURSEMENT)

1 Name of the Employee Y.Gangi Reddy

2 Designation and Basic pay S.G.T, Basic pay Rs 7970/-

3 Section and Office in which Employed

4 Actual Residential Address with Door No D.No.12/153,Cental Excise Colony,Sai Nagar,Anantapur

5

DR.M.Venkata Krishna Murthy

6 Dentocare Super Speciality Hospital, Anantapur ,

7 smt resma wife of Y.Gangi Reddy

8 Nature of the Decease Sever Attrition,Badly decayed teeth

( copy enclosed )

9 From 10-10-09 to 20-10-09

10 Details of Medical Charges incurred

I MEDICAL ATTENDENCE

a)NO Fee Rs

1 100

b)

c)

d) 8660

Essentiality Certificates and Bills are Enclosed here with

II HOSPITAL TREATMENT

a) Accommmodation charges

b) Pharmacy Charges

c) Lab Charges (Details Shall be furnished)

d) Surgeon's Fee

e) Assist.Surgeon's Fee

f) Anesthetic fee

g) Theatre Charges

h) Blood Charges

i) Nursing Charges

11 Total Amount Claimed 8660

12 Less Advance Received

13 Net Amount Claimed 8660

14 No.Of Enclosures

FORM OF APPLICATION FOR MEDICAL CLAIMS

EDN SECTIOM MPUP SCHOOL, CHADULLA, SINGANAMALA Mandal, Anantapur .Dt

Office and place where wife / husband is Employed

Name of the Medical Attendent and address and Name of the Hospital with Regd No

Name of the Patient and his / her relation ship to the Govt Servent ( In the case of children, state Age also)

Period of treatment as in-patient as indicated in the certificates &Hospitalisation

The Number and Dates of Consultaions and Fee paid for each consultaion

The Number and Date of Injections and fess paid for injections

Details of Laboratory Tests,X-rays ,and Scan etc

The Number and Dtae of Costs of Medicines(Details of the consolditated Medicines shall be furnished in the Essentiality Certificate)

DECLARATION TO SIGNED BY THE GOVERNMENT EMPLOYEE

M.E.OM.P.SINGANAMALA

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


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

APPENDIX -II (MEDICAL REIMBURSEMENT)

1 Name,Designation & SectionY.Gangi Reddy

S.G.T EDN SECTIOM

2 Office in which Employed MPUP SCHOOL CHADULLA


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 )


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

MPUP SCHOOL, CHADULLA, SINGANAMALA , Anantapur .Dt

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

M.P.SINGANAMALA


APPENDIX -II (MEDICAL REIMBURSEMENT)

Y.Gangi Reddy

S.G.T EDN SECTIOM

MPUP SCHOOL CHADULLA


TOTAL

15705

Rs 5750--13030

D.No.12/153,Cental Excise Colony,Sai Nagar,Anantapur

smt resma wife of Y.Gangi Reddy

Residence

From 10-10-09 to 20-10-09

( copy enclosed )

Rs 8660/-

Essentiality Certificates and Bills Enclosed here with

#VALUE!

Emergency Certificate

Discharge Summary

Dependence Certificate

( All Originals in Duplicate Submitted )


APPLICATION FOR CLAIMING REFUND OF MEDICAL EXPENSES INCURRED IN CONNECTION WITH MEDICAL ATTENDENCE AND / OR TREATMENT OF GOVERNMENT EMPLOYEE AND THEIR FAMILES

MPUP SCHOOL, CHADULLA, SINGANAMALA , Anantapur .Dt

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

NON - DRAWL CERTFICATE

Signature of the drawing and disbursing officer

Signature of the applicant.

DEPENDENT CERTIFICATE

Signature of the applicant.

Signature of the forwarding officer

This is to certify that the amount of Rs 8660/-.( Rupees eight thousand six hundred and

sixty only ) has not been paid previously ,towards medical reimbursement in respect of smt resma

w/o Sri Y.Gangi Reddy, S.G.T, MPUP SCHOOL, CHADULLA, SINGANAMALA Mandal,

Anantapur .Dt ,on his/her treatment taken during the period from 10-10-09 to 20-10-09 for the

Disease Consultation.Root canal treatment,Ceramic crowns, in the hospital Dentocare Super

Speciality Hospital Anantapur, and this is the first Spell for the disease and entered in the Medical

Reimbursement Register

I, Sri Y.Gangi Reddy, S.G.T, MPUP SCHOOL, CHADULLA, SINGANAMALA Mandal,

Anantapur .Dt hereby declare that smt , resma has no property of income of his/her own and that

he/she is wholly dependent on me. He/she is also not a employee or pensioner.

SRINIVAS GANDHAMANENI - 99594 22002 - 94402 69989

APTC FORM - 58

FULLY VOUCHRED CONTINGENT BILL

Payble at

For the Month & Year 12 2009DIST TREASURY OFFICE

DTO (PLANED)

District: Anantapur For Treasury use OnlyDate:-

D.D,O`s T.B.R.No Trans ID:-

1 0 0 1 Major Head 2 2 0 2

DDO Code: 1003567-0092 Sub - Major Head 0 1 Ele..Edn.

DDO Designation: M.E.O Minor Head 1 0 3

DDO, Office Name.

M.P.P

M.P.SINGANAMALA Group Sub - Head

Bank Branch Code 80 Sub - Head 0 5

Bank Branch Name: SBI Detailed Head 0 1 0 Salaries

B.K.SAMUDRAM

Sub - Detailled Head 0 1 7

Non-Plan = N/ Plan =P N Charged = C/ Voted = V: V 2 0 2

Gross Rs : 8660 Deduction Rs : - Net Rs:_ 8660

F tvÀô È¢ÀÀh¸åné ±µÃ8660 ( eight thousand six hundred and sixty only )

.F ¶mSµlµÀ / VÇOµÀÖ / f¸ñ¶pÁýà / P¹h¸Y¶¢À / ¶ª±µÀç s¹dÀ l¸ö±¸ VÇwôAVµAfº.

ËÈpOµ¶¢ÀÀdºà¶ml¼

f¸ñ VÉÊª Clû¼O¸±¼


FOR USE IN TREASURY / PAY & ACCOUNTS OFFICE ONLY

Pay Rs ……………………… (Rupees……………………………………………………………………………………..

……………………………………………………………………………………………………………………………………

…………………………………………. Only) by Cash / Cheque / Draft / Account Credit as under and Rs ……………

(Rupees ……………………………………………………………. Only) by adjustment.

TREASURY / PAOCODE

GeneralEducation

Asst. to local Bodies ,

Teaching grant to M.PS.

Medical reimbursment

Contingency Fund MH/Service Major Head

±µÃq¸±ÀµÀvÀ ¶¢ÃhµñÊమే

1. Rs……………………… by transfer credit to the S.B. Accounts of the employee (As per Annexure - 1)

2. Rs……………………… by trancefer credit to the D.D.O. Account towards non - government deducations.

NBST / Bank Seal

Treasury Officer / Pay & Accounts OfficerSrinvas Gandhamaneni - 99594 22002 * 9440269989 "www.apteachers.blogspot.com"

PARTICULARS OF AMOUNT CLAIMED IN THIS BILL

Amount

/2008

8660.00

Total 8660.00

( eight thousand six hundred and sixty only )

Non - Drawel Certificate

This is to certify that the amount climed in this bill was not drawn and paid previously

Total Amount Rs : 8660.00



sfÇÝd³ £¶¢±¸vÀ1. 2008

±µÃ :

±µÃ :

±µÃ :

1.Budget provided for the year

2.Expenditure including this bill

3.Balance


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.

¶ªA¶¢hµù±¸nOº sfÇÝd³ OÉd¹±À³ÀA¶pÁ

2. FtvÀôhÐ ¶ª¶¬ C±ÀÀ¶m ¶¢ö±ÀµÀA

3. nvÀ¶¢

ANNEXURE-I(Notifide Pay Bank) (Employee Wise Details)

Name of the NPB: SBI , B.K.SAMUDRAM NPB Code : 80

D.D.O.Code : 1003567-0092 Date : 12/12/2009

D.D.O.Designation: M.E.O

M.P.SINGANAMALA

S.No Employee Code Name of the Teacher Employee SBI A/C NoAmount

1 11111234567 Y.Gangi Reddy 123456789023 8660.00

TOTAL 8660


Assistant Treasury OficerM.E.OM.P.SINGANAMALA ANANTAPUR

ANNEXURE-II(Notifide Pay Bank) (Employee Wise Details)

Name of the NPB: SBI , B.K.SAMUDRAM NPB Code : 80

D.D.O.Code : 1003567-0092 Date : 12/12/2009

D.D.O.Designation: M.E.O Trance-ID: 0M.P.SINGANAMALA

S.No Name of the NPB Purpose

1 SBI , B.K.SAMUDRAM 8660

TOTAL 8660


M.E.OAssistant Treasury OficerM.P.SINGANAMALA

ANANTAPUR

Trance-ID:

Amount to be credited

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


Signature of the Signature of the Bank Officer Treasury Officer(With Seal) (With Seal)



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


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.



DTO ,ANANTAPUR

SBI ,B.K.SAMUDRAM

8,660

8,660

Signature of the Treasury Officer

(With Seal)



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


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


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)

Date :- 12/12/2009D.D.O., Anantapur 1 0 0 1

Trans ID : 345

D.D.O. Code 1001-0308-01District : ANANTAPUR

D.D.O.Designation HEADMASTER DDO Office Name : Mandal ParishadGHS NO.1 Anantapur Anantapur Rural

Bank Code 0 2 5 0 Bank Name : SBI,ANANTAPUR

D.D.O.' s TBR No:-. Permanet / Temporary:-

Head of Account Deductions

Major Head General Education 1 GPF/AIS/PF Rs.

2 APGLI Rs.

Sub Major Elementary Education 3 Group Insurance/AIS Rs.

4 Professional Tax Rs.

Minor Head 5 House Rent Rs.

6 Festival Advance Rs.

Group Sub-Head 7 Apco Advance Rs.

8 Education Advance Rs.

Sub Head 9 H.B.A. (P) Rs.

10 H.B.A. (I) Rs.

Detailed Head Salaries 11 Car Advance (P) Rs.

12 Car Advance (I) Rs.

13 Motor Cycle Advance (P) Rs.

Non-plan=N/Plan=P N Charged=C/V V 14 Motor Cycle Advance (I) Rs.

Voted=V : 15 Cycle Advance Rs.

16 Marriage Advance (P) Rs.

17 Marriage Advance (I) Rs.

011 Pay Rs. 3662.00 18 Income Tax Rs.

012 Allowances Rs. 19 Class IV GPF-DTO Rs.

013 Dearness Allowance Rs. 1066.00 20 E.W.F. Rs.

015 HRA Rs. 493.00 21 ZPPF (8338) Rs. 5233.00016 CCA Rs. 12.00 22 Rs.

IR 0.00 Total Govt. Deductions Rs. 5233.00Gross Amount Rs. 5233.00 Total Non-Govt. Deduction Rs.

Less Amount Rs. 5233.00

AG Net Amount Rs. 0.00 Total Deductions Rs 5233.00

AG Net Amount in words

D.D.O's SignatureFOR USE IN TREASURY / PAY & ACCOUNTS OFFICE ONLY

Pay Rs. …………...………….……... (Rupees …………………………..…………………………………………………

………………………………...……………………………..…only) by Cash / Cheque / Draft / Account Credit as under and Rs. ……………………………………………………….

(Rupees ………………………………..………………………………………………………………………………………………only) by

1

2

Treasury Officer / Pay & Accounts Officer

Assistance to Local

bodies on primery Edn

Teaching Grants to M.Ps

Contingency Fund MH/ Service Major Head

Rs. …………………. ……………………………..By transfer credit to the S.B. Accounts of the employees (As per Annexure - I).

Rs. …………………………………………………….. by transfer credit to the D.D.O. Account towards non-government deductions.

NBST / Bank Seal

K36

SONY: PAY + P.P

K37

SONY: HMA+PHC

X39

SONY: ZPPF + PF LOAN

BUDGET DETAILS

1. BUDGET ALLOTMENT FOR THE YEAR Rs.

2. EXPENDITURE INCLUDING THIS BILL Rs.

3. BALANCE Rs.

DDO

The bill amount Rs 5833

( )

Received Amount Rs

DDO

DDO

Required Certificates

1 Certified that the Amount was not drawn paid previously.

2 Certified that the Pay Amount was calaimed G.O.MS.No. 180 Dated 29-6-06

3 Certified that the D.A. Amount was Claimed G.O.MS NO 139.Dated 5-6-08

4 Certified that the D.A. Amount was Claimed G.O.MS NO 19,Dated :-2-2-07

5 Certified that the D.A. Amount was Claimed G.O.MS NO :-133,Dated:-12-06-07

6 Certified that H.R.A. Amount was Claimed G.O.MS.No.181,Dated 29/06/2006

7 Certified That C.C.A Amount was Claimed G.O.MS.No.182,Dated 29/06/2006

8 Certified That I/R Amount was Claimed G.O.MS.No.303,,Dated 15/10/08

9 Certified that the Pay Amount was calaimed G.O.(P).No. 241 Dated 28-09-2005

10 G.O.M.SNo.54 Education ( SE-SER-III) Departmrnt dated 02-08-07.

11 G.O.M.SNo.38 Education ( SE-SER-III) Departmrnt dated 26-05-07.

12 Certified that necessary entries were made in the individual S.R

DDO

FOR USE IN ACCOUNTANT GENERAL OFFICE

m.r.bill-mandal

Documents

cental excise

authorised

notifide pay

root canal

accountant

medical reimbursment

mandal educational

medical expenses