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Hospital/Provider Empanelment Request
Payer
*
Payer Scheme
*
.
Provider Entity Name
*
Hospital/Provider Ownership
*
Select
Corporate
Government
Semi-Government
Trust
Proprietary
Charitable Trust
Private Limited
Public Limited
Leased
Partnership
Hospital/Provider New?
Existing
New
Hospital/Provider Type
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BLOOD BANK
DIAGNOSTIC CENTER
HOSPITAL
PHARMACY
Address (Site, Street, Area)
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City/Location
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Pincode
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District
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Landmark
State
Country
Telephone
*
Mobile
Fax
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Email
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Alternate Contact No.
Alternate Email Id
Alternate Communication Address
Web Address
MD/CEO Name
*
Mobile
*
MD/CEO Email
*
Fax
Medical Care Establishment Registration Details
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Registration Number
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Registration Date (dd/MM/yyyy)
*
Expiry Date (dd/MM/yyyy)
*
Registration Doc (PDF/DOC/JPG)
*
Declaration form (PDF/DOC/JPG)
*
Hospital Photo (PDF/DOC/JPG)
*
OTHER INFO or ACCREDITATIONS AND CERTIFICATIONS
TAX & PAN Card Details
PAN Type
PAN
*
TAN
Service Tax Reg. No.
Permanent
Temporary
Corporate
Name on PAN Card
*
PAN Card Address
*
Father/Promoter Name
Date of Incorporation/ Date of Birth (dd/MM/yyyy)
Scanned File (PDF/JPG/DOC)
Tax Exempt - TDS%
Exempt : From Date - To Date [DD/MM/YYYY]
Tax Exempt Reason
Yes
No
-
Service Tax Reg. Validity From-To [DD/MM/YYYY]
Tax Exempt Certificate (PDF/JPG/DOC)
TAN Certificate (PDF/JPG/DOC)
Service Tax Certificate (PDF/JPG/DOC)
-
Provider Bank A/C Details
Bank
*
Bank Branch
*
Branch Code
IFSC Code
*
Account Type
*
Account No.
*
Beneficiary Name of the Account
*
Current
Savings
Provider DMO/Health Camp Coordinator/Functionaries/Users Details
*
Provider Speciality wise Infrastructure Details
General Infrastructure
Provider/Hospital Bed Strength
General Ward Beds (Total)
No. of Beds (Male)
No. of Beds (Female)
THEATRES Infrastructure
General Ward Theatres No.
ICU facility (No. of beds)
Post-op facility(No. of beds)
Step-down facility(No. of beds)
Categories wise Bed Infrastructure
Diagnostic facilities available: (in house)
*
Basic Diagnostic Details
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Pathology and Biochemistry (PDF/JPG/DOC)
ECG
X-Ray/Radiology
Advanced Diagnostic Facilities Available
Details
Document (PDF/JPG/DOC)
Yes
No
If No Advanced Diagnostic, Then TieUp Facility
Distance of TieUp Facility (KM)
MoU Document (PDF/JPG/DOC)
Diagnostics/ Critical Facilities Details
Equipment Details
Anesthetist Details
Round the clock anesthetist facility
Anesthetist
Mobile
Email
Yes
No
Registration Number
Qualification
College/University
Years of Experience
Provider Past Performance
OP and IP Patient Cases Volume
Department
2018-2019
2017-2018
2016-2017
Out-Patients
In-Patients
Specialists Details
*
Speciality
*
Specialist Name
*
Registration No.
Doctor Type
*
Select Speciality
Select Specialist Type
Select Specialist Type
Qualification
Experience Years
#Cases handled
Contract Type
Mobile Number
*
Select
MBBS
BDS
BAMS
BHMS
BUMS
BNYS
BPT
MD
MS
M.Ch
DNB
Dip
DM
FCPS
MCPS
PhD
MPT
MDS
MS(ENT)
DNB(ENT)
MASLP
M.Sc(Audiology)
M.Sc(Speec & Hearing)
MS(ORTHO)
Others
Full-Time Permanent
Part-Time Permanent
Full-Time Contract
Part-Time Contract
Full-Time Trainee
Part-Time Trainee
On Probation
MC Certificate (PDF/JPG)
*
Other Staff Details
Department
*
Staff Name
*
Job Role
Qualification
Select Department
Accounts & Finance
Customer Relations
Customer Technical Support
General Administration
House Keeping
Human Resource & Recruitment
Investor Relations
IT Administration
Legal
Marketing & Corporate Relations
Operations
Production/Engineering
Purchase, Supply-Chain
Research & Development
Sales & Business Development
Technology Hardware Development
Technology Software Development
Press Relations
Technical Maintenance
Insurance Operations
Top Management
Medical Services
Medical Services Planning and Commissioning
Operations and Strategy
Project Coordination
Project Planning and Budget
Project Execution
Protocols and Public Relations
Systems Protocol and IT
Clinical-Obs and Gynae
Clinical-Emergency
Clinical-Neonatology
Clinical-Anesthesia
Clinical-Dermatology
Clinical-Dietetics
Nursing
Medical Technician
Facility Maintenance Services
Food and Beverage
Retail
Select
X /Secondary School
XII Standard(Higher Secondary)
B.A
B.Arch
B.B.A
B.Com
B.Ed
B.Pharma
B.Plan
B.Sc
B.E/B.Tech
BCA
BDS
BGL
BHM
BVSC
CA
CS
Diploma PG
ICWA
Integrated PG
ITI
LLB
LLM
M.A
M.Arch
M.Com
M.Ed
M.Pharma
M.Sc
M.Tech
MBA/PGDM
MBBS
MCA
MCM
MPHIL
MS
MVSC
PG Diploma
Ph.D/Doctorate
SLP/B.Ed
B.Sc (Speech & Hearing)
BED III
BSLPA
BASLP
Others
Experience Years
Contract Type
Mobile Number
*
Remarks
Full-Time Permanent
Part-Time Permanent
Full-Time Contract
Part-Time Contract
Full-Time Trainee
Part-Time Trainee
On Probation
Details of Faculty-Full time,Consultants, Duty Doctors and Para Medical Staff with Scanned Certificates (DOC/PDF)
Future Expansion Plans
Authorized Applicant Information
*
Department
*
Applicant Name
*
Job Role
Email ID
*
Select Department
Accounts & Finance
Customer Relations
Customer Technical Support
General Administration
House Keeping
Human Resource & Recruitment
Investor Relations
IT Administration
Legal
Marketing & Corporate Relations
Operations
Production/Engineering
Purchase, Supply-Chain
Research & Development
Sales & Business Development
Technology Hardware Development
Technology Software Development
Press Relations
Technical Maintenance
Insurance Operations
Top Management
Medical Services
Medical Services Planning and Commissioning
Operations and Strategy
Project Coordination
Project Planning and Budget
Project Execution
Protocols and Public Relations
Systems Protocol and IT
Clinical-Obs and Gynae
Clinical-Emergency
Clinical-Neonatology
Clinical-Anesthesia
Clinical-Dermatology
Clinical-Dietetics
Nursing
Medical Technician
Facility Maintenance Services
Food and Beverage
Retail
Telephone Number
*
Fax Number
Mobile Number
*
PreView and Print Application Form and Package Rates
Documents
Uploaded Files(PDF/DOC/XLS/XLSX/JPG)
*
Remarks
Signed and Sealed Application Form
Signed and Sealed Package Rate List
Remarks
*
DECLARATION:
We accept the Procedure List with the Respective Rates and the other
Terms & Conditions
of the Payer Scheme.
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