1

22.4
1577778/2018/F SEC-STATEAUDIT

MUNICIPAL ADMINISTRATION DEPARTMENT

I

From
Tp
B Chinnapa Reddy,
The Director,
Examiner of Accounts,
State Audit Department,
Municipal Corporation,
Andhra Pradesh,
GUNTUR.
GUNTUR.

Lr.EOA/SA/ No.11/2018 Dated.27.07.2018

Sub: - Medical Reimbursement - Medical treatment to daughter of B.Chinnapa

Reddy, EOA, MC, Guntur- Treatment for Bilateral Fess and Septoplasty
under GA - Sanction of reimbursement ot medical expenses requested -
Regarding. !

***
I
!
It is submitted that my daughter Ms. B.Sai Sri Kir'an aged 22 years has obtained
treatment for her nose ailment and under gone a prqcedure of Bilateral Fess and
Septoplasty under GA on 10.02.2018 in Vijayawada Multi. Specialty Hospital,
Vijayawada. The application for reimbursement of medical expenses incurred for the
'
said treatment of Rs.55, 145/- along with all required bill$ and certificates are submitted
for scrutiny and necessary action. The claim has beeni uploaded in Employee Health
Scheme portal.

In this regard, I am to request that sanction orders for reimbursement of medical

expenses my kindly be issued early.

IIYours~
aithfull , I

!I '2,">'">~

( BiCHINNAPA REDDY)
Examiner of Accounts,
Guntur Municipal Corporation,
Guntur.

Encl: Appliaction along with all the enclosures in triplicate

i ..
i
 2
1577778/2018/F SEC-STATEAUDIT

7/16/2018 ,ti. Print Application

I MEDICAL REIMBURSEMENT FORM i

Employee Details
I i
I Name:CHINNAPA
IEmp Type:Employee IIEmp ld:0909036
REDDY
Employee
Mobile
Email:[email protected] Designation:EXAMINER
Number:9492392427
I OF ACCOUNTS
I

Address Details I
I ! i
I
!Residential Address: i I
House No:37-1-4(170/10) S Street No:SANTHAPET,
State:Andhra Pradesh
1203 SAIBABA TEMPLE, ON(pOLE
1District:GUNTUR l!villages/Cities/Towns: : I
!office Address: '
House No:326 PRAKASAM I

Street No:TRUNK ROAD State:Andhra Pradesh

BHAVANAM
. ,District: PRAKASAM l!viltages/Cities/Towns: I
I Employee Pay Details I
!Pay Source:GOAP PRC jiPRC:2010 llcurrent Pay:28450 I
I POSTING DETAILS 1
I
ODO Code:Examiner Of
HOD Name:Director State v\ccounts Municipal I
i
I
I District:GUNTUR
Audit Corporation(EOA,MC) i
I
(06010703006)

I Treatment Details I I
Treatments For:BUSI Patient Name:BUSI REDDY
Patient Gender:Female
REDDY SAi SRI KIRAN SAi SRI KIRAN I

Patient Date Of
~ge:23
I Relation With
Birth: 19/08/1994 : Employee:Daughter

Its Hypertensive: N lits Diabetic: N

'
i!Patient Type: IP I
Date Of ~ Date Of Total Amount
Admission:09/02/2018 Discharge: 10/02/2018 Claimed:55145-
http://www.ehs.ap.gov. in/EH SAP /claimreimbursment.do?actionFlag=initiateReimbursement&claimld=APM R 13 7 54/1 B&declF ormFlg=Y 1/2
I
 3
1577778/2018/F SEC-STATEAUDIT

Print A pplication

Hospital Name:Vijayawada
Hospital State:Andhra Multi SpecialityHospital ( f. Hospital
Pradesh unit of durgaBhavani Distric:VIJAYAWADA
II
Hospitals Pvt.ltd. I

I Declaration
I
I
i I

I hereby declare that the statement in the application is true to the best of my
knowledge and belief 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 1972 and wholly dependent upon me.

~;,,--
Signature of HOD/ODO I
with Office Seal Siqnature of Govt.Servant/Pensioner
I
I
Examiner of Accounts i
i
Municipal Corporation, Guntur'

http://www.ehs.ap.gov.in/EHSAP /claimreimbursment.do?actionFlag=initiateReimbursement&claimld=APMR 13 7 54/18&dec1FormFlg=Y 2/2

' ,
 - - - ···- -- -----------· -- -- ··----··-· -·------c------------
4
1577778/2018/F SEC-STATEAUDIT
Vijayawada Multispeciality Hospital
-----·--·--··- ---------·-·-···----------·-··-
(A UNIT OF DURGA BHAVAN/ HOSPITALS PVT. LTD.)
29-8-3, Chiluku Durgaiah Street, Nakkal Road 1st Cross, Vijaya Talkies Centre, Suryarao Pet,
VIJAYAWADA-520002. Phones: 0866-6660133/2435666

Date: 28th February 2018.

EMERGENCY CERTIFICATE

This is to certify that Ms.sai sri Kiran, aged 22 years/Female, D/0

B.Chinnapareddy , Examinor of accounts, Municipal Corporation , Guntur, Guntur

District, Andhra Pradesh is a case of "BILATERAL FESS + SEPTOPLASTY

UNDER GA'' on 10-02-2018 at and she was admitted in Vijayawada Multi Speciality

Hospital on 09-02-2018 under stable condition and was discharged on 12-02-2018.

CONSULTANT SIGNATURE
 5
1577778/2018/F SEC-STATEAUDIT

ESSENTIALITY CERTIFICATE
(Tobe completed in the case of patients who are admitted to hospital for treatment)
Certificate Granted to Mr./ Mrs. 1:, • 2)£\.i< S<J:<L \(1..)l.O..,S::O aged cl~ yrs Male/
Female
Dr f\~ }•----;-
\lx;;---;;,
.1:J>
-----,,----
b~ fCl
~Q.. ~.----::-t::f\-,---
--------,~
r:Cl
-~~----. &°"'f?>~~-F.J-¢~-f
· ~, .;i..i - -. . .)~~~~~~~~
,. PART-1 , <

(Tobe signed by the Medical Officer incharge of VIJAYAWADA MULTI SPECIALITY HOSPITAL,
VIJAYAWADA) ~ .
Dr."''
certify
\0:{ t°~ _\TIJAYAWADA MULTI SPECIALITY HOSPITAL, VIJAYAWADA here by
@)
A. That the patient was admitted to ~ ~
• 0 0 "
+
()\J0 e_t:, ,
on the advice of B\ t: P~ +-S "bf-nh O t"\ <l, J '1, ~ fi .
B. That the patient has been under treatment atVUAY~MULTI SPECIALITY HOSPITAL
VIJAYAWADA, and that the under mentioned medicines prescribed by me in the connection were essential
for the recovery/ ( prevention of serious deterioration in the condition of the patient).

S.No Bill No. Date Place where the medicines purchased/ Investigations done Amount

C. That the injections administered are/ were not for immun~~r·prophylactif pufose.
D. That the patient is He/She is/ was under treatment from '6 to \;il_i &. {1S-
E. (!)That the X- Ray, Laboratory tests etc. For which an expenditure of Rs ~
(ll)For Surgery, Minor Procedures etc. For which an expenditure of Rs :?>9 1 O C\ () \ ~
(lll)For Drugs a_nd ~on:umables for Which expenditure of Rs ~ 1 G 46 \ .--
(IV)And other Hospitalization Rs \ ~ 1 Q ~ () .
As incurred were necessary and were> under taken the advice ai VIJAYA\VA.DA MULTI SPECIALITY
HOSPJTAL, VIJAYAWADA ( Name of the Hospital Or Laborato~ ~
F. That I Called on Dr N • \('1 {2>~'1.0 \<n u:d:il,
J lll~dr~~a{ consultation and that the Necessary
approval of the _
( Name of the Chief Admin . Medical Officer) as required under rules was obtain1~/
1
J/ " // /~·.
I( \j 1-,/v,/yK,v-L..f_p.,~,
Signature andfoesignation of Medical Officer 1/C
PART II Or. N,. Krishna Kantr.
M.S.,(Eir
r certify that the patient has been under treatment at the VUAYAWADA MdLTJ S~I~f'IOSP~6,0
VIJAYAWADA. Hospital for which the expenditure of Rs £5 1 14::-5 - incurred vide bill and receipts
attached were essential for the recovery / prevention of serious deterotation in the condition of rtie patient. /) -4/f/"' -",
fi\ CY . ~,~/"[°"~$'-.
Signature and D4ligribfic:n'of Medical Officer J/C
COUNTER SIGNED or. N,. Rrishna Ka1u,,
M.S.,(ENi
I Certify that the patient has been under treatment at the VIJAYAWADA MULTI ~eg&rtiGIOS-!liM(?
VUAYAWADA and that the facilities provided were minimum which were essential for the patient's treatment.
Date:
Signature and Dtg1rrion of Medical Officer l/~
I \(~~--Rv\Y._)!_~tJ;_··
Dr. N Rrisfma0 Kanr~,
. M.S.,(EN ·
~egd- ~o ~566C
 6
1577778/2018/F SEC-STATEAUDIT Vijayawada Multispeciality Hospital
{A UNIT OF DURGA BHAVANI HOSPITALS PVT. LTD.)
29~8-3, Chiluku Durgaiah Street, Nakkal Road 1st Cross, Vijaya Talkies Centre, Suryarao Pet,
VIJAYAWADA-520002. Phones: 0866-6660133/2435666

Name: Ms. Sai Sri Kiran B MR No: MR042810

Age/Gender: 22Y/F Visit ID: IP006105
Address: Guntur Admission Date: 09-02-2018 21 :54
Location: VIJAYAWADA. ANDHRA PRADESH Discharge Date: 12-02-2018 19:32
Doctor: Dr. N. Krishna Kanth , M.S, ( ENT) Ward/Bed: Non A/C Single Room/ROOM 204
Departm ent: ENT Referred By: Self
DISCHARGE SUMMARY
1. DIAGNOSIS :
Chronic sinusitis + DNS Right.

2. SURGERY:
Bilateral fess+ Septoplasty under G.A on 10.02.2018 at 08:00.

3. CHIEF COMPLAINTS:
Complaints of Bleeding left Nostril. Left Nasal Block. Headache on and off since 3 months.
Loss of smell since 3months.

4.COURSE IN THE HOSPITAL:

Patient was admitted , pre-operative profile done. Pre-anaesthetic checkup done and was posted for surgery Bilateral fess+
Septoplasty under G.A. Post operatively patient was treated with iV fluids,PPIS, Antibiotics, Analqesics, Antihistaminics, Anti
emetics.Per-operative and Post operative period was uneventful , nasal pack removed and patient was discharged in stable
condition.

5.ADVISE AT THE TIME OF DISCHARGE :

1. Tab. Rabicer-D 7am-0-7pm Before Food 5days

2. Tab.Mox-cv 625mg 9am--0-9pm After Food Sdays.
3. Tab.Levocad 5mg 9am--0-9pm After Food Sdays.
4. Tab.Acyclo -P 9am--0-9pm After Food Sdays.
5. Nasolix Nasal Drops Sdrops- Stimes- Sdays.

6.REVIEW AFTER 5 DAYS/ SOS

Follow Up Details C:\ /~AIL J/,... :1to·-
11

16-02-2018 Dr. N[~;ifma Ka~,~~~ UP VISIT

)

0,.. N.. Krishna Kantif

M.S.,(EN"'i
ltE!od~ ~o: ~5660
 7
1577778/2018/F SEC-STATEAUDIT

DECLARATION TO BE SIGNED BY THE GOVERNMENT

SERVANT/PENSIONER

I hereby declared that the statement in the application is 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 Government

servant Medical Attendance Rules, 1972 and wholly dependent on me.

~;/
Signature of Government Servant/
Pensioner
Place Guntur

Date 25-4-2018
 8
1577778/2018/F SEC-STATEAUDIT
,·

APPENDIX II FORM
APPLICATION FOR CLAIMING REFUND OF MEDICAL EXPENSES INCURRED IN CONNECTION WITH
MEDICAL ATTENDANCE AND TREATMENT OF GOVERNMENT SERVANT AND THEIR FAMiLIES

1. Name and designation & Section B. CHINNAPA REDDY

(in block letters) EXAMINER OF ACCOUNTS

2. Office of the employee Municipal Corporation, Guntur

3. Pay of the Govt. servant cs defined in

FRs and other employments which
Be shown separately : Rs.67990/-

4. Place of Duty : GUNTUR

5. Full residential address with Door No.

6. Name of the patient, his/her relation-

Ship to the Govt., servant, and in case Ms. B. SAi SRI KIRAN
of children, state age also Daughter (22 years)

7. Place at which the patient fell ill Guntur

8. Nature of illness and its duration : BILATERAL FESS + SEPTOPLASTY UNDER

GA
Duration - 'l-2-2018 to 12-2-2018
9. Details of amount claimed, cost of
Medicines purchased from the market/
List of medicines, cash memos. and
The Essentiality Certificate should be
Attached each in duplicate signed
By Doctor/s. who had given the
Treatment UST ENCLOSED

10. Total amount claimed : Rs.55, 145-00

11 . List of enclosures : 1. Check list

2. Essentiality Certificate
3. Emergency Certificate
4. Consolidation of bills
5. Discharge Summary
6. Medical cash bill
7. Non Drawal Certificate
8. Hospital recognition G.O.

~~

~inn,....f.11ro
 9
1577778/2018/F SEC-STATEAUDIT

NON DRAWAL CERTIFICATE

Certified that the claim of reimbursement of medical expenses incurred

by B. Chinnapa Reddy, Examiner of Accounts, Municipal Corporation, Guntur on
treatment to his daughter Ms. B. Sai Sri Kiran, for BILATERAL FESS + SEPTOPLASTY
UNDER GA amounting to Rs.55,145-00 (Rupees Fifty Five thousand, One hundred
and forty five only) was neither preferred nor drawn previously.

~~,t
Signature and designation

Examiner of Accounts
Municipal Corporation, Guntur
 ·~ ~-------·-
10
1577778/2018/F SEC-STATEAUDIT

DEPENDENT CERTIFICATE

Ms. B. Sai Sri Kiran D/o Sri B. Chinnapa Reddy, Examiner of Accounts,
Municipal Corporation, Guntur is not employee / Pensioner and fully dependent on
me and she has no other source of income and completely dependent on me.

/~'
~ Signature of the
Signature of the !=orwarding Authority.
Govt.Servant Examiner of Accounts
Municipal Corporation, Guntur
 11
1577778/2018/F
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pmpoi,o t11' l1t,11ln1t11l ht S1i1ln Ut~);~t.uucnl Emph,yt•c•,, ltcl,rc;d l'cm,11>11<.'a,,
111111 their 1l1,pc1ulo11l!., M.1..A,.,,\l_lx. MI..!\~. hntl 1lll11:1 cnlcl_',tlfld ,,f
11r,1r,(1111, n, per nth"• · lli.'n•;111ili•l!1't;J1:lc1~ l:<:,11c,I l\~1~111di111.!.

l~cl'- I. (LO, lvh No. l/,2 IIM,HW fi(,l'},Pcpll Dated. ;\. -US-20l1S
2. n.o Ms. N" ,1 I I IIM&l'W l{f;J 1),•pll ll::lcd. ·11,.(111.;.00S.
:t. lm,pc.:11<111 Hcp1111 l.f.lk.N11,.ll!{(fGlllloll/:::lll7, DI 0/,. \ l-:!!ll'i !1<1111 th,:
Supud11lc1nlu111, I'""' <lr11<'1ul lll~~piJ,d, Vijnynwnd11
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Irom 211.12.1111 ·110 o:,.O:Zi.!0111.

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···~·
111 exeroisc of tho pO\\'OI'~ dck1tnlc<l to him i111ht:,l'l:forc1wc!l clted, the l )11 cctoi111' klml1<:;il hlui:ation,
Andhru l'r:11111:m, V\j.1y11watln, ls plua1:,c,I nccord n1t'.<>1~11itio11 to of Mh Vijayawada Mullispccialily
It)
Hor.pita.I (/\ unll of D11rgn Bh,wru,i Houpllnlu, l~vl.. Ltd). V1pyawr1da a:, iclcn al l111;;pi1nl for
lhc $pcui11lilic:1 of Gc1111111l Mod kine, ncnrn1l };11rger);,·Ot1hopallilic:,, ENT. P11l11,,11mln1:~. l'la:;lic Smgcry
lt<1almont to the ~111ct\•ll'ics 111c111i,,11cd in the •,1i!'1jcc1 u11 rd111l1111:m1111•11l hu,1:; 1111(1,ii llm lollowini.;.
C()tli~l\01\,~ (OU! ,r..:, in p~liOll\S).
\; 'fho \l(l(;})\\ll\!; :,hi\\11,l til\'t} fn,c lft'IIUIICIII H>·sWhilO cmd hohlc1!, or hcl(>W p,:n·1,tl}' line to 0
rninim11111 5% ,,fbcd strcuyJh (for inpa1ic111 r.u1;\1lcc:.).
2. Thr llos11ital t;hould 1,tivc free tm!<lkal 11cal11;;,;ill lo r.tudcm:; or S.C. I S.'I I \\.<". 1c:;ide11lial
:td1uols, s;r. l\:,lnumn Schon I:., S.T. I ln~tds, G.V .V,K. Scluwl~ un<I Mnuhndi Sd11u>h.
J. TI\Ct Ho~\;i\n\ ~h,111\<I p1,1vi,k heller 111ctliu11l 1111d·hc11llh $1m1lcc$ i11cl111li11f: free tliag110,aic :;c1vicc~.
,•(111d11~,111~ h1:n\1h cmnp:,, l)lli:C in a 111u11lh i111wo "iit.iucs which urc 111-:ntilJnctl in ih,· M O.IJ.
•I. Tlic llospi111\ ~houhl s11\1mil monthl)• 1ctur11 i111hc· prc~cril11:1l lr,1111a1.
5. Pnd:a\l',c 11\\c, for Eye 11il111c11l', J.hnuld hens prc5cril>cd in <.i.OM~.NlJ.·1.1, JIM,\iFW (ICI)
Dcpl\lU11c111, n .. ted. 15-0J-l005 nnd n~ mnc-ndcd frum lime Ill 1im.:. The J>i11:r101 or Mei.lic:il
\:dm.,n1ion / St111tini1i111\ >lllthorily sh;,11 "crify nnd cn~urc 1hn1 the rha,uc~ kv•~·d h~· 1hc·J•riv:,lc
Bospllnbt :1l't· .;.,~ 1n·1 tho :ihnvc :-ale~. lt,:fou~ 1,;c,ii!Yinu the net ::d11u .... :;..lblc a.1nt!u1u If the ralc!~ of
Privalc l!ospitah ;,re Ir:,;. 1hu11 tlv.: C U.1-1.S, p;,ckn1\c rnte!; ! (illVl'flllllt:111 rntc·; a·. rci l111!1cx11n: lo
1l1c ,11id G.O. !ht' t n,'C!-1 rntc!, ,1r I', iv111c Hospilal:, ::hull be acccptc,1 lilr ~c1111in:, :ual pn)•,nc:11.
6, The I lo~pital :;honlll pny I,:,. :tU,()()ll/- (Rupee:, Thirty Thc,11::auds (>nly) h"•"'arcb 111~pcc1io11 rec
cwry ycnr.
7. All mhcr guidclinr.s 111cnti,mc\l i:: lh\'. rdc.rcnc.c!; ,;\t0uld Ile follownl ~cr11p11lou:.:li.
6. '111c pcrmi~~io11 acco1Jcd 10 the• ho:,p:lal b liable th, c11nccl111tion mid such otlu:r action as dc.cmcd
lit, iududing dc-rccClgnilion of th<' hu~pi1nl mai 111i1iutc crimi1ml aclion us pc, law o~uinsl the
hospilnl. whenever lhc S1111c (iov ... nunclil tc,nm, the <,pinion hai:cd on in$pcclion ,ir enquiry in10 ·
tho 11l101:111iu11s !h:il Ilic m1;tl .l11 h•111t: Ho~p1lal ir. tml prn\'idinr, 11 rnln1cnt 10 1!1t, !:o.wtc Gnvcrnmcnl
Employco, / ltdi1l'd 1'111ployun:, 111111 lhc,ir dop,\11tlcnl~ clc., "~ ~lip11l:1lcd 11lu.wc 111111 ,·inhuc:, lhc
condi~ion~ 111cutiu11cd thc1d11, uml i11d11l1:c· nny ir:ci;:1luriti~ in rcspccl ,,f c:-.c.css ! hO[\US clnims,
chcnltll[\ 1hc p:i1iim1 or Govcnllil~'.111 or r.:i;onln1.: 101111)' 1111111;,vfiil n.:1ivltics c\C., ill'tt,· giving fil'lcc11
( 15) d:iy~ 1101icc m the ho:,pilnl 'aml pa:;s npproprlnlc order::, nlhl1 c,m~idcri111.t lhc rcpr,'.sc11la1io11,
if any, olicrctl by lhc :;nid llo:,pi111l. •

9. Thc.sc order.; nrc v111itl rwm 06.02.?.0lll to ()5.0:U0.19.

10. t\11 scn11ini1.i11g ofliccrs ~hould follow thc:,c 1;11iduli11c,; i11 ml111l1tin1\ 1h,1 hilk

Sd/· Dr. N. S11hba R1111

Dirt•.:1t,r of Mcdi,•nl l.':1l11u11•t•n

//,1\Ucs1ed// 0 . -Ji;:~,. .,
.. S'f~Uirm::mr or~iiJi.ff!c1uc1,1inn
Io: -{1;,..5\,0\f.
~ys V\jnyawadn Mt11lis1mclalily lfo~;pilal (A unil of Durn:-1 Blwvnni Hm;pllnl~;. Pvl.. Ltd),
V11nyawado
The ~O. Dr.NTH Vaidya Sc\•a Trus1~ Chtt11Uf:1111w. Gun1t1r
All the Heads ofDcpnnmcnts.
1lu: Pay ~ud Accounts Ofiiccr, lbrnhimpa1na111, Vijay:iwnd:i.
All the Oi51rlct Trcnmt)' Officers in 1hc S:01.:. . .

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 --·----- -~-·- -··--·--·---·-··
12
--
1577778/2018/F SEC-STATEAUDIT

CHECK LIST

'
l . Name and address of the B. CHINNAPA REDDY
Employee- Employee Code : Employee Code No.0909036
CFMS Code : 14222165

2. If retired- , WORKING
a) DateiYear of Retirement
b) Designation
c) P.P.O. No.

3. Communication Address of the Flat No.40 l, Brundavan Towers

Applicant for all purposes with 2nd Line, Vidya Nagar
Cell No. : GUNTUR
Cell No.9849908373

4. Name and address of the Hospital : VIJAYAWADA MULTIJSPECIALITY

a) Whether it is a private hospital (or) HOSPITAL, 29-8-3, Chiluku Durgaiah
Recognised hospital : Street, Suryaraopet, VIJAYAWADA

b) Whether referral letter produced

(or) Recognised orders to be Copy of G.O., in which the hospital
Enclosed along with the proposals : was recognized is enclosed

5. Whether the Medical Reimbursement

Proposals sent within 6 months from
Date of discharge Yes

6. Whether the following are enclosed

l ) Appendix II duly attested by the

Head of the office : Yes
2) Emergency Certificat_e : Yes
3) Discharge Summary : Yes
4) Non Drawal Certificate : Yes

5) Essentiality Certificate attested by

the authorized doctor, who
undertakes treatment Yes

6) If the patient is dependent on the

Govt., employee. An Employee
certificate and dependency
certificate are to be enclosed
with the medical reimbursement Patient is daughter to the
proposals : Employee

7) In case of the dependents of

deceased Govt. Employee/Retired
employee whether legal heir
certificate is enclosed ( or) not
 ---------··---
13
1577778/2018/F SEC-STATEAUDIT

8) Whether the medical reimbursement

Proposal is prepared and submitted
With reference to G.O.Ms.No.7 4
HM & FW (K 1} Dept .. Dt.15-3-2005
And G.O.Ms.No.60, HM & FW (Kl)
Dept .• Dt.15-10-2003 and also G.0.
Ms.No.105, HM & FW (Kl} Dept .•
Dt.9-4-2007 and also G.O.Ms.No.180.
Dated 11-5-2006 : Yes

7. Whether the medical reimbursement

Claim is processed through the
Drawing Officer and received within the
stipulated time : Yes

8. And whether the availment of No.

of installments recorded ( or} not : Yes

9. Whether an entry is made in the

Service Register ( or} not for the
previous claim : Yes

~w
SIGNATURE OF FORWARDING AUTHORITY
Examiner of Accounts
Munic\pa\ Cm:poratign1 f;1:mfl:'T
 14
1577778/2018/F SEC-STATEAUDIT
Vijayawada Multispeciality Hospital
(A UNIT OF DURGA BHAVANI HOSPITALS PVT. LTD.)
29-8-3, Chiluku Durgaiah Street, Nakkal Road 1st Cross, Vijaya Talkies Centre, Suryarao Pet,
VIJAYAWADA-520002. Phones: 0866-6660133/2435666

IN PATIENT DETAILED BILL

Name: Ms. Sai Sri Kiran B Bill No: BL18001183
Age/Gender. 22Y F Bill Date: 12-02-2018 19:32
Address: Guntur MR No: MR042810
Location: VIJAYAWADA,ANDHRA PRADESH Visit ID: IP006105
Doctor: Dr. N. Krishna Kanth , M.S, ( ENT ) Admission Date: 09-02-2018 21 :54
Department: ENT Ward/Bed Non A/C Single Room
Rate Plan: GENERAL Discharge Date: 12-02-2018 19:32
Sponsor: Referred By: Self

Charges Ord# Head Descdption Rate Qty Amount

Registration
12-02-2018 Admission Charge 200.00 1.00 200.00
12-02-2018 Medical Record Charges 300.00 1.00 300.00
Sub Total: 500.00
Ward Charges
09-02-2018 Bed Charges ROOM 204 1,200.00 4.00 4,800.00
09-02-2018 Nursing Charges ROOM204 1,000.00 4.00 4,000.00
09-02-2018 Consultant Charges ROOM 204 800.00 4.00 3,200.00
Sub Total: 12,000.00
Services & Procedures
Surgery Package-Septoplasty + Fess
12-02-2018 167523 Service 30,000.00 1.00 30,000.00
under GA
12-02-2018 167523 Service Coblator Charges 9,000.00 1.00 9,000.00
Sub Total: 39,000.00
Medicines and Consumables
12-02-2018 Pharmacy Sales Bill Pharrnacy sales bill No. SB1899G5 524.oo/ 1.00 524.00
11-02-2018 Pharrnacy Sales Bill Pharrnacy sales bill No. SB189818 4.00 •. , 1.00 4.00
11-02-2018 Pharrnacy Sales Bill Pharrnacy sales bill No. SB189816 325.00 X'" ·1.00 325.00
11-02-2018 Pharrnacy Sales Bill Pharrnacy sales bill No. SB189795 1,307 .OCY · j.00 1,307.00
10-02-2018 Pharrnacy Sales Bill Pharrnacy sales bill No. SB189758 58.oQ,/'1.oo 58.00
10-02-2018 Pharrnacy Sales Bill Pharrnacy sales bill No. SB189725 1,278.00 .,, •; 1.00 1,278.00
10-02-2018 Pharrnacy Sales Bill Pharrnacy sales bill No. SB 189693 149.00 /'1 1.00 149.00
Sub Total: 3,645.00

Payments Receipt No Mode Card Type Bank Reference No Amount

Advance
10-02-2018 RC18061967 Cash 10,000.00
Advance
10-02-2018 RC18062189 Cash 15,000.00
Advance
12-02-2018 RC18062557 Cash 26,500.00

Net Payments: 51,500.00

Bill Summary

Signature
 15
1577778/2018/F SEC-STATEAUDIT
VIJAYAWADA MULTI SPECIALITY HOSPITAL
( A Unit of Durga Bhavani Hospitals Pvt. Ltd.)
#D.No:29-8-3, Chiluku Durgaiah Street, Nakkala Road, Suryaraopet

GSTIN - 37AADCD7431J1ZJ Duplicate Cash Bill DL No - 103036/37

Patient : Ms. Sai Sri Kiran B Doctor : Dr. N. Krishna Kanth , M.S, ( ENT)
Bill No : SB189693 Date : 10-02-2018 14:14
MR No : MR042810 Hosp. Bill No: BP18031893
s Exp Total
Item Name HSN Code Qty Mfr Batch No Rate GST%
No date. Value
1 KLOTIN 1 OOMG/5Ml 30049099 1 Neon 38023 03/19 70.50 5 70.50
2 INJ TROPINE-1 Ml 30044010 1 Neon KP38002 01/19 3.90 5 3.90
3 · NIRLIFE NS-500 Ml 30045020 1 NIRL 1K76466 10/20 28.47 12 28.47
4 NIRLIFE RL 500 ML 30045020 1 NIRL 2J72138 09/20 46.11 12 46.11

Tax%
5%
Value
. 3.55
CGST
1.78
SGST
1.78
t· ~
12% 7.99 4.00 4.00
18% 0.00 0.00 0.00
28% 0.00 0.00 0.00
NOTE: RETURNING OF MEDICINES Will NOT BE ACCEPTED

VIJAYAWADA MULTI SPECIALITY HOSPITAL

( A Unit of Durga Bhavani Hospitals Pvt. ltd.)
#D.No:29-8-3, Chiluku Durgaiah Street, Nakkala Road, Suryaraopet.

GSTIN - 37AADCD7431J1ZJ Duplicate Cash Bill DL No - 103036/37

Patient : Ms. Sai Sri Kiran B Doctor : Dr. N. Krishna Kanth , M.S, ( ENT )
Bill No : SB189725 Date : 10-02-2018 17:03
MR No : MR042810 Hosp. Bill No: BP18031925
s Exp Total
Item Name HSN Code Qty Mfr Batch No Rate GST%
No date. Value
1 INJ ZOSUL 1.5 GM 30042019 2 CIPL C870388 04/19 477.50 12 955.00
2 INJ PANSEC IV 40MG 30049039 2 CIPL AFM7163 05/19 44.24 12 88.48
3 INJ EMESET -2 ML 30049035 2 CIPL l670232 06/20 11.89 12 23.78
4 INJ INTAGESIC 3004 2 INTA NT021 08/19 17.50 12 35.00
5 INJ DEXADRAN- 2ML 30043913 2 SEAR V10973 12/18 5.85 12 11.70
6 NS 1 OOML NIRLIFE 30045020 2 NIRL 2J72034 09/20 16.07 12 32.14
7 SYRINGES 10cc - OMNIVAN 90183100 2 BBR 17H31M8203 07/22 22.00 12 44.00
8 SYRINGES 5CC - OMNIVAN 90183100 2 OMNI 17G14M8202 06/20 14.00 12 28.00
9 SYRINGES 2cc - OMNIVAN 90183100 6 OMNI 17K22M8203 08/22 10.00 ~
~-:;,. ,....:._..,,,. 60.00

~ ~:jil::..4j~.oo
/: r,~,- . ·"" ~.£6.
** INCLU~..,_,._f, ;;: ~LL **

Tax% Value CGST SGST ~~f.Y .l5i . lit (f;{!i _.;:1'.

~~~
'jt.
~
1
.
osy
..,_.
,.<::).'I

12%" · 136.93
~
68.46 68.46
18% 0.00 0.00 0.00
 I~---.-~-
16
1577778/2018/F SEC-STATEAUDIT
.VIJAYAWADA MULTI SPECIALITY HOSPITAL
( A Unit of Durga Bhavani Hospitals Pvt. Ltd.)
#D.No:29-8-3, Chiluku Durgaiah Street, Nakkala Road, Suryaraopet.

GSTIN - 37AADCD7431J1ZJ Cash Bill DL No - 103036/37

Patient : Ms. Sai Sri Kiran B
Doctor : Dr. N. Krishna Kanth , M.S, ( ENT)
Bill No : SB189758
Date : 10-02-2018 22:04
MR No: MR042810
Hosp. Bill No· BP18031955
s
Item Name HSN Code Qty Mfr
Exp Total
No Batch No Rate GST°/c,
date. Value
1 TAB MONCEL-FX 30049069 4 HELi VT0544 09/19 14.40 12 57.60
Grand Total: 58.00
** INCLUSIVE OF ALL TAXES **
Krishna
User Name : k .
uman
Tax% Value CGST SGST
5% 0.00 0.00 0.00
12% 6.17 3.08 3.08
18% 0.00 0.00 0.00
28% 0.00 0.00 0.00
NOTE: RETURNING OF MEDICINES WILL NOT BE ACCEPTED
/
_.(

VIJAYAWADA MULTI SPECIALITY HOSPITAL

( A Unit of Durga Bhavani Hospitals Pvt. Ltd.)
#D.No:29-8-3, Chiluku Durgaiah Street, Nakkala Road, Suryaraopet.

GSTIN - 37AADCD7431J1ZJ Duplicate Cash Bill DL No - 103036/37

Patient : Ms. Sai Sri Kiran B Doctor : Dr. N. Krishna Kanth , M.S, ( ENT )
Bill No : SB189816 Date : 11-02-2018 15:34
MR No: MR042810 Hosp. Bill No: BP18032010
s Exp Total
Item Name HSN Code Qty Mfr Batch No Rate
No GST%
date. Value
1 INJ PAARMOL-IV 3004 1 RANB GZR0086 11/18 325.00 12 325.00

Tax% Value CGST SGST

5% 0.00 o.oo 0.00
12% 34.82 17.41 17.41
18% 0.00 0.00 0.00
28% 0.00 0.00 0.00
NOTE: RETURNING OF MEDICINES WILL NOT BE ACCEPTED
~ ......,..,.._. ... ,.... ,,-,,

17
1577778/2018/F SEC-STATEAUDIT
VIJAYAWADA MULTI SPECIALITY HOSPITAL
•, ( A Unit of Durga Bhavani Hospitals Pvt. Ltd.)
#D.No:29-8-3, Chiluku Durgaiah Street, Nakkala Road, Suryaraopet.

GSTIN- 37AADCD7431J1ZJ Cash Bill DL No - 103036/37

Patient : Ms. Sai Sri Kiran B Doctor : Dr. N. Krishna Kanth , M.S, ( ENT )
Bill No : SB189795 Date : 11-02-2018 12:25
MR No : MR042810 Hosp. Bill No: BP18031989
s Batch No
Exp
Rate GST%
Total
Item Name HSN Code Qty Mfr
No date. Value
1 INJ ZOSUL 1.5 GM 30042019 2 CIPL C870388 04/19 477.50 12 955.00
2 INJ PANSEC IV 40MG 30049039 2 CIPL AFM7163 05/19 44.24 12 88.48
3 INJ EMESET -2 ML 30049035 2 CIPL L670232 06/20 11.89 12 23.78
4 INJ INTAGESIC 3004 2 INTA NT018 08/19 17.50 12 35.00
5 NS 1 OOML NIRLIFE 30045020 2 NIRL 2J72034 09/20 16.07 12 32.14
6 INJ DEXADRAN- 2ML 30043913 2 SEAR V10973 12/18 5.85 12 11.70
7 TAB MONCEL-FX 30049069 2 HELi VT0544 09/19 14.40 12 28.80
8 SYRINGES 10CC-OMNIVAN 90183100 2 BBR 17H31M8203 07/22 22.00 12 44.00
9 SYRINGES sec - OMNIVAN 90183100 2 OMNI 17G14M8202 06/20 14.00 12 28.00
10 SYRINGES 2cc - OMNIVAN 90183100 6 OMNI 17K22M8203 08/22 10.00 12 60.00

.
y,J:~ ~ v· Grand Total: 1307.00
** IN¢LUS1VE OF ALL TAXES**
/ User Name : Blessy
Tax% Value CGST SGST
5% 0.00 0.00 0.00
12% 140.02 70.01 70.01

VIJAYAWADA MULTI SPECIALITY HOSPITAL

( A Unit of Durga Bhavani Hospitals Pvt Ltd.)
#D.No:29-8-3, Chiluku Durgaiah Street, Nakkala Road, Suryaraopet

GSTIN - 37AADCD7431J1ZJ Duplicate Cash Bill DL No - 103036/37

Patient : Ms. Sai Sri Kiran B Doctor : Dr. N. Krishna Kanth , M.S, ( ENT )
Bill No : SB189905 Date : 12-02-2018 14:04
MR No : MR042810 Hosp. Bill No: BP18032091
s Exp Total
Item Name HSN Code Qty Mfr Batch No Rate GST%
No date. Value
1 TAB MOX CV 625MG 30041030 10 RANB NBS0206 03/19 18.26 12 182.56
2 !TAB RABICER-D 30049039 10 BIOC BD17634 06/19 11.71 12 117.05
3 ITAB ACYCLO-P 1 OS 3004 10 Bio- ACP170702 06/19 4.50 12 45.00
4 !TAB LEVOCAD-5 MG 30049039 10 2YDU ZSIOOOS 11/20 4.00 12 40.00
5 !TAB SALVIT-M 21069099 10 SALU SLT1724 03/19 7.90 18 79.00
_......,.
6 NASOLIX-20 ML 30049099 2 MARK EL013 11/19 30.00 ,-, _;··~""'- ~ 60.00
,;:.;,~ -~

Tax% Value CGST SGST

. /y· ** INCLUSlyit.;<?~i~ **
User~~sy
.-· \
- --~;,.~ .

/<:::::, i•
_;' - '~-.>~,'\ / (;;JI
~
5% 0.00 0.00 0.00 ~~ -I ~·...~
~'\if. .,. :, "
·-,::::-:.:-· .
12% 47.64 23.82 23.82
18% 12.05 6.02 6.02
28% 0.00 0.00 0.00
NOTE: f:{l;TURNING OF MEDICINES WILL NOT BE ACCEPTED
---··-···"""·--·-.,.; .; -=-;a..;;.a----------·- --· -· 18
1577778/2018/F SEC-STATEAUDIT
VIJAYAWADA MULTI SPECIALITY HOSPITAL
( A Unit of Durga Bhavani Hospitals Pvt. Ltd.)
#D.No:29-8-3, Chiluku Durgaiah Street, Nakkala Road, Suryaraopet

GSTIN - 37AADCD7431J1ZJ Duplicate Cash Bill DL No - 103036/37

Patient : Ms. Sai Sri Kiran B Doctor : Dr. N. Krishna Kanth , M.S, (ENT)
Bill No ; S8189818 Date : 11-02-2018 16:51
MR No: MR042810 Hosp. Bill No: BP18032011
s Exp Total
Item Name HSN Code Qty Mfr Batch No Rate
No GST%
date. Value
1 !TAB LEVOCAD-5 MG 30049039 1 ZVDU ZS10005 11/20 4.00 12 4.00

TIDC°/o
5%
12%
18%
Value
0.00
0.43
0.00
CGST
0.00
0.22
0.00
SGST
0.00
0.22
0.00
,~ 7· 1ct

28% 0.00 0.00 0.00

NOTE: RETURNING OF MEDICINES WILL NOT BE ACCEPTED

~··- -.. "'; ..

.I