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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)*


OTHER INFO or Accreditation or CertificationEffective Date (dd/MM/yyyy)Upload File
AERB DOCUMENTS
KPME CERTIFICATE
NABH CERTIFICATE
POLLUTION CONTROL BOARD CERTIFICATE
TRADE LISENCE CERTIFICATE
 
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 *
Provider DMO/Health Camp Coordinator/Functionaries/Users Details*
Functionary TypeFunctionaryMobileFaxEmail
SAMCOCO - SUVARNA AROGYA CAMP CO ORDINATOR
SAMCO-SUVARNA AROGYA MEDICAL CO ORDINATOR
Provider Speciality wise Infrastructure Details
SpecialityAvailableAvailable for HealthCampSpecialist 24x7OTSterillityTotal BedsICU Beds#Beds for Post-op facility#Beds for Step-down facilityEquipment in theatres
BURNS
CARDIOLOGY
CARDIOTHORACIC SURGERY
CARDIOVASCULAR SURGERY
COCHLEAR IMPLANT
DENTAL
ENDOCRINE
ENDOSCOPIC
ENT
GENERAL MEDICINE
GENERAL SURGERY
GENITO URINARY SURGERY
HYSTEROSCOPIC
INVESTIGATIONS
MEDICAL ONCOLOGY
NEURO SURGERY
NUCLEAR MEDICINE
OBSTETRICS AND GYANAECOLOGY
OPTHALMOLOGY
ORTHOPAEDICS
PAEDIATRIC SURGERIES
POLYTRAUMA
RADIATION ONCOLOGY
SURGICAL ONCOLOGY
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)
CategoryAvailableTotal Beds#Beds for Female#Beds for MaleEquipmentsEquipment Photo File
BLOOD BANK - INHOUSE/TIE UP
BURNS AND PLASTIC SURGERY
CARDIOLOGY / CARDIOTHORASIC SURGERY
CHEMOTHERAPY
CT - INHOUSE/TIE UP
ECHO- INHOUSE/TIE UP
MRI - INHOUSE/TIE UP
NEONATAL/PEDIATRIC SURGERIES
NEUROSURGERY
ONCOLOGY
PATHOLOGY - INHOUSE/TIE UP
POLYTRAUMA
RADIOTHERAPY
RENAL/UROLOGY
SURGICAL ONCOLOGY
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)

Diagnostics/ Critical facilitiesAvailable24x7If No, Working HoursInHouse or OutSourcedUpload Affidavit File
BIOCHEMISTRY From To
BONE CONDUCTION TEST - FILL ONLY FOR COCHLEAR IMPLANT From To
ECG From To
GENERAL WARD - MIN 50 BEDS From To
HAEMATOLOGY From To
IC U - MIN 3 BEDS From To
LAMINAR AIRFLOW OT - FILL ONLY FOR COCHLEAR IMPLANT From To
MICROBIOLOGY From To
OT- LAMINA FLOW PATTERN From To
PAEDIATRIC INTENSIVE CARE UNIT FULLY EQUIPPED - FILL ONLY FOR COCHLEAR IMPLANT From To
PAEDIATRIC RESUSCITATION FACILITY - FILL ONLY FOR COCHLEAR IMPLANT From To
POST OP WITH VENTILATOR AND PAEDIATRIC RESUSCITATOR FACILITY - FILL ONLY FOR COCHLEAR IMPLANT From To
POST OPERATIVE WARD - MIN 2 BEDS From To
PURE TONE AUDIOMETRY - FILL ONLY FOR COCHLEAR IMPLANT From To
SEROLOGY From To
SOUND PROOF ROOMS -10’X 10’ - FILL ONLY FOR COCHLEAR IMPLANT From To
STEP DOWN ICU WARD - MIN 2 BEDS From To
USG From To
VENTILATED 10 X 10 ROOM EXCLUSIVELY FOR AUDITORY-VERBAL THERAPY - FILL ONLY FOR COCHLEAR IMPLANT From To
X-RAY From To
Equipment Type#EquipmentsEquipment ModelsUpload File
ABR WITH FACILITY FOR CLICKS AND TONE BURSTS/ASSR - FOR COCHLEAR IMPLANT ONLY
BENAIR MICRO MOTOR - FOR COCHLEAR IMPLANT ONLY
BOYLE’S APPARATUS
DC SHOCK CONVERTOR
DIAGNOSTIC PURE TONE AUDIOMETER WITH FREE FIELD - FOR COCHLEAR IMPLANT ONLY
DIATHERMY
ENDOSCOPES
FACIAL NERVE MONITOR - FOR COCHLEAR IMPLANT ONLY
IMPEDANCE AUDIOMETER - FOR COCHLEAR IMPLANT ONLY
LAPAROSCOPIC EQUIPMENT
MICROEAR SURGERY INSTRUMENTS - FOR COCHLEAR IMPLANT ONLY
MONITOR
OPERATING MICROSCOPE
OPERATING MICROSCOPE WITH VIDEO RECORDING FACILITY - FOR COCHLEAR IMPLANT ONLY
OTO-ACOUSTIC EMISSION INSTRUMENT - FOR COCHLEAR IMPLANT ONLY
PULSE OXYMETER
SKEETER/ANGLED HAND PIECE AND MICRODRILL FOR COCHLEOSTOMY - FOR COCHLEAR IMPLANT ONLY
STERILITY UNIT
SUCTION APPARATUS
TELE-METRIC EQUIPMENT - FOR COCHLEAR IMPLANT ONLY
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 2017-2018 2016-2017 2015-2016
Out-Patients
In-Patients
 
Specialists Details*
Speciality* Specialist Name* Registration No. Specialist 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 accept the Procedure List with the Respective Rates and the other Terms & Conditions of the Payer Scheme.