Empanelment of Dental Clinic - ECHS

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20SECTION IIIINSPECTION REPORT AND RECOMMENDATIONS OF QCI (NABH)Recommendations of the QCI (NABH)1.………………………………………………………………………………………..(Name of Hospital/ Nursing Home/Diagnostic Centre/Hospice) is recommended/notrecommended for empanelment for Ex-Servicemen Contributory Health Scheme(ECHS) for service offered by the institution.2. The Specialities of……………………………………………………………………….. (Name of Hospital/Nursing Home/Diagnostic Centre/Hospice) listed in the table below are recommended/notrecommended for empanelment for Ex-Servicemen Contributory Health Scheme(ECHS).(Note : Mention R for Recommended and NR for Not Recommended. Strike out specialitiesnot offered for empanelment with an X)(a)(b)General Services(i) DentalSpecialised ServicesRemarksof QCI(NABH)(i)(ii)(iii)(iv)(v)(vi)Oral & Maxillo Facial SurgeryPeriodontiaProsthodontiaEndodontiaOrthodontiaPaedodontiaSeal of NABHSIGNATURE OF THE AUTHORIZED OFFICEROF NABH/QCI
AnnexureCHECK LIST FOR DOCUMENTS FOR EMPANELMENT APPLICATIONS OF ______________________________________________________________________TELE NO _____________________ RC, _______________________Ser Name of Documents Applicable(Yes/No)1. CD CONTAINING SCANNED COPY OFAPPLICATION.2. HARD COPY AND CD TO TALLY.3. PAGES OF APPLICATION/ ANNEXURES TO BESERIALLY NUMBERED.4. AUTHENTICATION OF EVERY PAGE BYAUTHORISED PERSON5. PARTNERSHIP AGREEMENT AND DEED DULYAUTHENTICATED BY NOTARY.6. PHOTOCOPY OF MRO FOR APPLICATION FEE-RS. 1,000.00 DULY AUTHENTICATED BYDIRECTOR, REGIONAL CENTRE ECHS7. PHOTOCOPY OF BANK GUARANTEE FOREARNEST MONEY-RS 1,00,000.00 DULYAUTHENTICATED BY DIRECTOR, REGIONALCENTRE ECHS.8. DD FOR INSPECTION FEE- DD IN FAVOUR OFQCI (FOR NON NABH)9. COPY OF CERTIFICATE OF STATE HEALTHAUTHORITY RECOGNISING THE HOSPITAL.10. COPY OF AUDITED BALANCE SHEET FOR LASTTHREE YEARS.11. COPY OF LEGAL STATUS FOR CONDUCTINGBUSINESS UNDER GOVT AGENCY(REGISTRATION & PLACE OF BUSINESS OFHOSPITAL).12. COPY OF CUSTOMS DUTY EXEMPTIONCERTIFICATE GIVING CONDITIONS OFEXEMPTION.13. PHOTOCOPY OF PAN CARD.14. NAME AND ADDRESS OF BANKERS.15. COPY OF EXISTING LIST OF RATES APPROVEDBY HOSPITAL.Attached(Yes/No)Date ofValidity ofCertificatesIf attached thenpage numberFrom ToRemarks
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 and 18: 15SECTION IIAPPLICATION FORMAT FOR
Page 19 and 20: 17PART III: HOSPITAL INFORMATIONSer
Page 21: 19(v)Orthodontist(vi)Paedodontist(f

Empanelment of Dental Clinic - ECHS

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