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Hospital/Provider Empanelment Request
Payer* Payer Scheme*
.
Provider Entity Name* Hospital/Provider Ownership*
Hospital/Provider New? Hospital/Provider Type*
Address (Site, Street, Area)*
City/Location* Pincode*
District* Landmark
State Country
Telephone* Mobile
Fax* Email*
Alternate Contact No. Alternate Email Id
Alternate Communication Address
Web Address
MD/CEO Name* Mobile*
MD/CEO Email* Fax
 
Medical Care Establishment Registration Details *
Registration Number* 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)*


 
TAX & PAN Card Details
PAN Type PAN* TAN Service Tax Reg. No.
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

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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)
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Provider Bank A/C Details
Bank* Bank Branch* Branch Code IFSC Code*
Account Type* Account No.* Beneficiary Name of the Account * Cancelled cheque(PDF/JPG/DOC)

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)
Diagnostic facilities available: (in house)*
Basic Diagnostic Details*
Pathology and Biochemistry (PDF/JPG/DOC) ECG X-Ray/Radiology



Advanced Diagnostic Facilities Available Details Document (PDF/JPG/DOC)

If No Advanced Diagnostic, Then TieUp Facility Distance of TieUp Facility (KM) MoU Document (PDF/JPG/DOC)

Anesthetist Details
Round the clock anesthetist facility Anesthetist Mobile Email
Registration Number Qualification College/University Years of Experience
Provider Past Performance
OP and IP Patient Cases Volume
Department 2019-2020 2018-2019 2017-2018
Out-Patients
In-Patients
 
Specialists Details*
Speciality* Specialist Name* Registration No. Doctor Type*
Qualification Experience Years #Cases handled Contract Type Mobile Number*
MC Certificate (PDF/JPG)*

 
Other Staff Details
Department* Staff Name* Job Role Qualification
Experience Years Contract Type Mobile Number* Remarks
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*
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 hereby accept the Ayushman Bharat- Arogya Karnataka scheme and agree to the Package Rates indicated in the Annexure 7A,7B,8&9 to GO:HFW/69/CGE/2018 dated 15.11.2018