Empanelment of Dental Clinic - ECHS
Empanelment of Dental Clinic - ECHS Empanelment of Dental Clinic - ECHS
16PART II: BACK GROUND INFORMATIONSer SubjectNo1. Historical BackgroundDate of EstablishmentRegistered/Not Registered*(with State Health Authorities)Information given by DentalClinicRemarks ofQCI (NABH)Type-Govt/Private/CorporateManagement(Individual/Corporate/Trust or any other– please specifyRecognition by other schemes –CGHS/KBS/AGIF/Rlys/PublicSchemes* - indicate which schemesare you linked with.Already empanelled with ECHS –Yes/No2. LocationDistance from nearest ECHS PolyclinicAvailability of public transportDistance from Railway station/Busstand/Air port to HospitalDistance from nearest Military HospitalSocial Environment – please indicatenatures of civic services, and whetherthe institution is in a rural, semi rural,urban or semi-urban area(Note: Attach relevant documents/certificates for items marked *)SIGNATURE OF THE AUTHORIZED APPLICANT
17PART III: HOSPITAL INFORMATIONSerNoSubject1. BuildingTotal AreaInformation given byDental ClinicRemarks ofQCI(NABH)Floor AreaNumber of Dental ChairsMacro environments-External AmbienceParking AreaWaiting AreaReception and waiting for Relatives (Specifyapprox area)(Notes: 1. An outline diagram showing plan of Hospital/Nursing Home may be added, if available.2. A Brochure, if available, may please be included.2. Miscellaneous (Specify) – You may include any other pertinent details, you feel necessary.SIGNATURE OF THE AUTHORIZED APPLICANT
- Page 1 and 2: INTRODUCTIONOn behalf of the Presid
- Page 3 and 4: SECTION ICHAPTER 1GENERAL INFORMATI
- Page 5 and 6: 3S/No Town/City Name of Regional Ce
- Page 7 and 8: 5Ser Type of City Minimum Bed Stren
- Page 9 and 10: 719. Non-NABH accredited hospitals
- Page 11 and 12: 9CHAPTER 3TERMS AND CONDITIONSCashl
- Page 13 and 14: 11(e)(f)(g)(h)(j)(k)(l)(m)(n)(o)(p)
- Page 15 and 16: 13(c) Copy of legal status, place o
- Page 17: 15SECTION IIAPPLICATION FORMAT FOR
- Page 21 and 22: 19(v)Orthodontist(vi)Paedodontist(f
- Page 23 and 24: AnnexureCHECK LIST FOR DOCUMENTS FO
16PART II: BACK GROUND INFORMATIONSer SubjectNo1. Historical BackgroundDate <strong>of</strong> EstablishmentRegistered/Not Registered*(with State Health Authorities)Information given by <strong>Dental</strong><strong>Clinic</strong>Remarks <strong>of</strong>QCI (NABH)Type-Govt/Private/CorporateManagement(Individual/Corporate/Trust or any other– please specifyRecognition by other schemes –CGHS/KBS/AGIF/Rlys/PublicSchemes* - indicate which schemesare you linked with.Already empanelled with <strong>ECHS</strong> –Yes/No2. LocationDistance from nearest <strong>ECHS</strong> PolyclinicAvailability <strong>of</strong> public transportDistance from Railway station/Busstand/Air port to HospitalDistance from nearest Military HospitalSocial Environment – please indicatenatures <strong>of</strong> civic services, and whetherthe institution is in a rural, semi rural,urban or semi-urban area(Note: Attach relevant documents/certificates for items marked *)SIGNATURE OF THE AUTHORIZED APPLICANT
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