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APPLICATION FORM
1. Name Of the Institution. _________________________________________________________
2. Address. ___________________________________________________________
_________________________________________________________
3. Tel No. ______________Fax ___________________E-Mail______________________________
- Types of Hospitals/ Diagnostic Lab( Multi specialty Hospitals., Single/Multi Super Specialty Hospitals /Lab & Diagnostic Services).
_____________________________________________________________________________
4A. Mention the type of specialty for which it is to be empanelled. _________________________
5. History of the Hospital (Track record for the last 2 years)
6. No. of Beds ____________
7. Man Power (Regular)
Medical/para-medical staff on regular basis and not on part-time basis. Detail Annexed-1 as per Empanelment policy. Minimum Medical and Para Medical staff norms for 100 bedded hospitals are as under:
Minimum Eligibility Criteria:
|
S.No.
|
Category
|
Minimum as per the norms
|
Available in the Hospital
|
|
1.
|
Physician/Surgeon
|
4
|
|
|
2.
|
Anaesthetist
|
1
|
|
|
3.
|
Pathologist
|
1
|
|
|
4.
|
Radiologist
|
1
|
|
|
5.
|
Casualty Medical Officers
|
3
|
|
|
6.
|
Medical Officer General Duty
|
1
|
|
|
7.
|
House Surgeons
|
5
|
|
|
8.
|
Dental Surgeon
|
1
|
|
|
9.
|
Physiotherapist
|
1
|
|
|
10.
|
Matron
|
1
|
|
|
11.
|
Nursing Sisters
|
5
|
|
|
12.
|
Staff Nurses
|
26
|
|
|
13.
|
Pharmacist
|
5
|
|
|
14.
|
Lab Technician
|
3
|
|
|
15.
|
Radiographer
|
1
|
|
|
16.
|
Lab Attendant
|
1
|
|
|
17.
|
OTA Assistant
|
1
|
|
|
18.
|
Storekeeper
|
2
|
|
|
19.
|
Clerk
|
2
|
|
|
20.
|
Accountant
|
1
|
|
|
21.
|
Head Clerk
|
1
|
|
|
22.
|
Cashier
|
1
|
|
|
23.
|
Carpenter
|
1
|
|
|
24.
|
Electrician
|
1
|
|
|
25.
|
Plumber
|
1
|
|
|
26.
|
Helper
|
2
|
|
|
27.
|
Cook
|
2
|
|
|
28.
|
Dhobi
|
3
|
|
|
29.
|
Chowkidar
|
3
|
|
|
30.
|
Mali
|
3
|
|
|
31.
|
Class-IV
|
30
|
|
8. Detail of regular Man Power employed to provide services of the Specialty for which hospital has applied for empanelment on the following format (Annexure-1):
8 A Specialty for which empanelment is applied:-
8B Medical and Para Medical Staff of that specialty on the following format:
|
Sr. No.
|
Name of the Doctor/Para Medical Staff
|
Qualification
|
Since Employed
|
|
|
|
|
|
9. Technical Parameters:
9A No. of OTs (Annexure-2)-
9B ICU - Detail of Medical and Para-medical staff employed on regular basis and list of equipments (Annexure-3).
9C CCU - Detail of Medical and Para-medical staff employed on regular basis and list of equipments (Annexure-4).
10. Lab Services: Detail of Medical and Para-medical staff employed on regular basis, list of equipments (Annexure-5)
11. Blood Bank: Detail of Medical and Para-medical staff employed on regular basis, list of equipments (Annexure-6)
12. Performance Report: (Last 2 years)
List of No. of Operations/procedures performed by the hospital for the last two years of the specialty for which application is submitted for empanelment (Annexure-7).
|
Sr. No.
|
Name of the operations/ procedure
|
Total no.
|
|
|
|
|
13. General Physical Guidelines
1. Multi Specialty hospitals. Detail Annexed as per Empanelment policy. Y/N______
2. Super specialty hospitals Detail Annexed as per Empanelment policy. Y/N______
3. Lab & Diagnostic Services Detail Annexed as per Empanelment policy. Y/N______
4. The hospital must have minimum following adequate infrastructure/logistic, confirming to the services provided by it such as:- Detail Annexed as per Empanelment policy. (Annexure-8)
· Gas Pipe line Y/N______
· Computerization Y/N______
· Ambulance service Y/N______
· Pharmacy Y/N______
· CSSD Y/N______
· Lifts & Ramp/Stairs Y/N______
· Kitchen/canteen Y/N______
· Fire fighting system Y/N______
5. Bio-medical Waste disposal system Detail annexed-9as per Empanelment policy. Y/N_____
6. Copy of the site plan duly approved by the competent authority and hospital should run from the legal authorized premises. Detail Annexed -10 as per Empanelment policy. Y/N____
7. Parking space. Detail Note Annexed -11 as per Empanelment policy. Y/N____
8. Easily accessible/approachable to the patients. Y/N____
9. Photocopies of Post graduate degrees (specialist/super specialists) of the specialist with the application. Detail Annexed-12 as per Empanelment policy. Y/N____
10. All facilities located in the same premises. Detail Note Annexed-13 Y/N____
11. Arrangement for the 24 hrs water supply. Detail Note Annexed-14 Y/N____
12. 24 hrs electricity supplies with the proper backup. Detail Note Annexed-15 Y/N____
13. Copy of the no objection certificate from the fire brigade. Detail Note Annexed-16 Y/N____
14. Bank Draft of Rs. 25,000/- in the name of “DGHS Reimbursement fund” Annexure-17-A
Bank Draft No. ______________ Name of the Bank_____________________
15. Agrees to pay Security of Rs. 1 lac in the form of Bank Draft in the name of “DGHS Reimbursement fund” which is refundable after the State Govt. grants approval for empanelment . Annexure-17-B Y/N _____
16. Agreement: Signed agreement on stamp Paper is annexed -18 as per empanelment policy
Y/N _____
17. Agrees to send a report to the O/o Director General Health Services, Haryana Panchkula regarding the patients who have taken treatment from the hospitals on quarterly basis.
Y/N _____
18. Agrees to put information showing validity of empanelment of Hospitals on the Notice Board at Reception. Y/N ______
19. Agrees to abide by all terms and conditions laid in the empanelment policy and agreement .
Y/N ______
20. Registration Certificate of Ultrasound Machine/s etc. Annexed-19. Y/N ______
21. Registration Certificate of MTP Annexed-20. Y/N ______
22. Registration Certificate from BARC for Radiation. Annexed-21 Y/N ______
23. Blood Bank License Annexed-22 Y/N ______
24. Any other document attached. Annexed-23
Signature& Designation of Competent Authority of the Hospital
(Note: GAMS/BAMS, ANM are not allowed to perform duties in place of MBBS Doctors, Staff Nurse. All the Medical/Para-Medical Staff should have requisite qualification as prescribed in the guidelines issued by the Govt. of India or the State Govt for performing duties in the Hospitals.)