Empanelment of Dental Clinic - ECHS

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