Registration No - ECHS

3S/No Town/City Name of Regional Centre Telephone No(ix) Pune Regional Centre ECHS 020-26331452C/O HQ Pune Sub AreaPune-410001(x) Chennai Regional Centre ECHS 044-25673092Fort Saint GeorgeChennai-600009(xi) Secunderabad Regional Centre ECHS 040-27797932C/O 404 AF Station BegumpetSecunderabad-500011(xii) Kochi Regional Centre ECHS 0484-2667285C/O Fleet Mail OfficeNaval BaseKochi-682004(xiii) Guwahati Regional Centre ECHSGuwahatiC/O HQ 51 Sub AreaPIN 900328c/o 99 APO0361-2642727

4CHAPTER 2GENERAL INSTRUCTIONS AND ELIGIBILITY CRITERIAGeneral Instructions1. Collection of Application Forms. Application form be downloaded from the website of Ex-Servicemen Contributory Health Scheme (ECHS). The form along with scanned copy in a CDshould be submitted with an application fee of Rs 1000/- (Rupees One Thousand only) in favor ofRegional CDA through MRO (Military Receivable Order) at any SBI Branch conducting Treasurybusiness or the RBI under the Code Head 405/03(Misc Receipt) towards application fee. Original tobe deposited at concerned Regional Centre and photocopy signed and stamped by Director,Regional Centre to be submitted with application.2. Categories of Cities. ECHS for purpose of empanelment has catergorised the cities asfollows :-(a) Type A. CGHS cities of Delhi and NCR, Kolkata, Chennai, Bangalore,Hyderabad, and Mumbai.(b) Type B. Balance CGHS cities.(c) Others. All other cities/ towns.3. Categories of Health Care Facilities. ECHS would consider the following categories ofhealth care facilities for empanelment :-(a)(b)(c)(d)(e)(f)(g)(h)Super Speciality Hospitals.NABH Accredited Hospitals.Non-NABH Accredited Hospitals.Cancer Hospitals.Speciality Eye Centres.Dental Clinics.Physiotherapy Centres.Rehabilitative Centres and Hospices.(j) Small Health Care Organisations (SHCOs), Nursing Homes, Single SpecialityHospitals, Allopathic Clinics, primarily for cities other than those covered by CGHS.Eligibility Criteria4. The Hospital/Nursing Home/Diagnostic Centre/Hospices should be registered with therespective State Health Authority as applicable. Diagnostic Centres/ Blood Banks should have thelicense of statutory authority.5. Following minimum beds are required for multispeciality hospitals (for single speciality thereis no restriction on bed strength) :-

5Ser Type of City Minimum Bed Strength(a) Type A 100 Beds.(b) Type B 50 Beds.(c) Others 15 Beds.6. The hospitals applying under super-speciality category must be accredited by NationalAccreditation Board for Hospital and Health care providers (NABH) or its equivalent such asJoint Commission International(JCI)/AHCS(Australia)/International Society for Quality inHealth Care (ISQua). The stipulation of minimum beds required will be as laid down by CGHS fromtime to time.7. Hospitals must have the capacity to receive and respond to electronic referrals throughinternet and submit all claims / bills in electronic format to ECHS and must also have dedicatedequipment, connectivity and staff for such equipment.8. Diagnostic Laboratories should preferably be accredited by National Accreditation Boardfor Testing and Calibration of Laboratories (NABL).9. Imaging Centres.(a)MRI Centre. Must have MRI machine with magnet strength of 1.0 Tesla and above.(b) CT Scan Centre. Whole Body CT Scanner with scan cycle of less than onesecond (sub-second). Must have been approved by AERB.(c)X-ray Centre/Dental X-ray/OPG Centre.(i) X-Ray machine must have a minimum current rating of 500 MA with imageintensifier TV system.(ii)(iii)(iv)(v)Portable X-ray machine must have a minimum current rating of 60 MA.Dental X-ray machine must have a minimum current rating of 6 MA.OPG X-ray machine must have a current rating of 4.5-10 MA.Must have been approved by AERB.(d) Mammography Centre. Standard quality mammography machine with lowradiations and biopsy attachment.(e) USG/ Colour Doppler Centre. It should be of high resolution Ultrasoundstandard and of equipment having convex, sector, linear probes of frequency ranging from3.5 to 10 MHz. Should have minimum three probes and provision/facilities of TransVaginal/Trans Rectal Probes. Must have been registered under PNDT Act.(f) Bone Densitometry Centre. Must be capable of scanning 3 sites (that includesSpine) and whole body.

6Instructions to Applicants10. Hospitals must agree to accept and abide by the terms and conditions spelt out in theMemorandum of Agreement.11. Hospitals must certify that they shall charge as per ECHS rates/negotiated rates whicheveris lower and which under no circumstances will be higher than the applicable CGHS rates notifiedby CGHS from time to time and that the rates charged by them are not higher than the rates beingcharged from their normal patients who are not ECHS beneficiaries.12. Hospitals must certify that they are fulfilling all special conditions that have been imposed byany authority in lieu of special concessions such as but not limited to concessional allotment of landor customs duty exemption etc.Last Date for Applying13. There is no cut off date prescribed for filling of empanelment applications. The applicationcan be submitted at ECHS Regional Centre any time on a working day.Earnest Money Deposit14. All the hospitals applying for empanelment will deposit Rs 1,00,000/- (Rupees one lac only)as EMD in the form of EMD Bank Guarantee in favour of respective Regional Centre, ECHS.The EMD is surety to sign MoA and will be refunded at the time of signing of MoA. Original BankGuarantee to be deposited at concerned Regional Centre and photocopy signed and stamped byDirector, Regional Centre to be submitted with application.Earnest Money Refund15. In case the application is rejected on technical grounds, Earnest Money would be refundedin full.16. In case, the application is rejected after inspection on the grounds of submitting incorrectinformation, then 50 % of the Earnest Money would be forfeited and the balance would be refundedin due course.17. In case, the applicant hospital refuses to sign the Memorandum of Agreement, 50 % of theEarnest Money would be forfeited. Authority to order for forfeiture of the EMD is MD, ECHS.Submission of Application Forms18. The application must be submitted at the following places :-(a) NABH Accredited Hospitals. At Central Organisation ECHS, Maude Lines, DelhiCantonment, New Delhi – 110010.(b) CGHS Empanelled Hospital. Submit application at Central Origination, ECHS afterdepositing original MRO and Bank Guarantee at concerned Regional Centre and getting thephotocopies signed and stamped by Director, concerned Regional Centre. These hospitalsmust submit the copy of Office Memorandum of Ministry of Health and Family Welfareempanelling the hospital with CGHS and copy of valid MoA signed with CGHS.(c)Non NABH Accredited Hospitals. Concerned Regional Centre.

719. Non-NABH accredited hospitals must submit their application alongwith fees for inspectionand assessing suitability for empanelment by QCI (NABH) in a form of demand draft in favour ofQuality Council of India payable at New Delhi as follows :-Ser Type of facility Bed Strength Inspection /Assessment Fee(Rs)(a) Hospitals More than 100 beds 35,000/-Less than 100 beds 30,000/-(b) Diagnostic, Eye &Dental CentresNot applicable 25,000/-20. Application forms should be submitted in one sealed envelope superscribed as ‘Applicationfor empanelment of hospital’.21. All the pages of Application and Annexures (each set) shall be serially numbered and spiralbinded.22. Every page of application form and Annexures need to be signed by the authorised signatoryof medical facility. The signatory must mention as to whether he is the sole proprietor or authorizedagent. In case of partnerships, a copy of the partnership agreement duly attested by a notaryshould be furnished. Similarly, in case of authorization, appropriate legal document should befurnished.23. As far as possible, all information should be given in the application. If a particular facility isnot available, it should be entered as ‘not available’; it should not be mentioned as ‘notapplicable’.24. The application is liable to be ignored if the information given on eligibility criteria is notcomplete.Scrutiny of Applications25. Applications shall be opened at the Regional Centres on the last Thursday of every month.In case the last Thursday of the month happens to be a holiday then the applications would beopened on the next working day.26. Every Applicant or his authorized agent can be present at the time of opening of theApplication forms in respect of that city / zone.27. The Director/Joint Director, Regional Centre will examine the application to determinewhether :-(a) They are complete.(b) Whether any computational errors have been made.(c) Whether Earnest Money Deposit and MRO has been furnished. Retain originals andattach photocopies duly authenticated by Director, Regional Centre with application.(d) Whether Draft for inspection / assessment fee has been furnished (only non-NABHaccredited).(e) Whether the documents have been properly signed and serially numbered.(f) Whether the application is generally in order.(g) Check list to be filled up, signed by authorised signatory of applicant andcountersigned by Director, Regional Centre.28. Defects / shortcomings will be corrected/ authenticated on the spot and the applicationprocessed further. Specific advice would be rendered by the Director, Regional Centres forrectification of incomplete applications. If the hospital wishes to submit fresh application, the MROof Rs 1000/- (Rupees one thousand only) can be reused.

829. Applications that are found to be complete in all respects shall be forwarded to CentralOrganisation ECHS for consideration of empanelment.Acceptance of Rates30. Hospitals shall have to furnish an undertaking to ECHS accepting the rates notified by ECHSor the negotiated rates which under no circumstances will exceed the applicable CGHS rates or therates being charged by the hospital from their normal patients who are not ECHS beneficiaries.Inspection of Hospitals31. QCI (NABH) would inspect the hospitals as part of assessment of hospital on behalf ofECHS (only non-NABH accredited Hospitals).Memorandum of Agreement32. The Private hospitals which are selected for empanelment will have to enter into anagreement with ECHS Regional Centre for providing services at rates notified by ECHS or lowernegotiated rates. This MOA has to be executed on Rs.100/- (Rupees One hundred only) nonjudicial stamp paper.Performance Bank Guarantee33. Hospitals that are recommended for empanelment after the assessment shall also have tofurnish a Performance Bank Guarantee valid for a period of two years at the time of signing MOAwith the Regional Centres to ensure efficient service and to safeguard against any default :-(a) Empanelled Hospitals - Rs 10.00 Lakhs(b) Eye Centre - Rs 2.00 Lakhs(c) Dental Clinics - Rs 2.00 Lakhs(d) Physiotherapy Centres - Rs 2.00 Lakhs(e) Rehabilitative Centres and Hospices - Rs 2.00 Lakhs(f) Diagnostic Laboratories / Imaging Centres - Rs 2.00 Lakhs34. In case of hospitals already empanelled under ECHS, they shall submit a new PerformanceBank Guarantee. The old performance bank guarantee will be discharged after its validity is over.

9CHAPTER 3TERMS AND CONDITIONSCashless Services1. The Hospital/Nursing Homes/Diagnostic Centres/Hospices shall provide the agreed uponservices to cases referred from ECHS Polyclinics on a Referral slip duly authenticated and stamped.Cashless services would be extended on credit system to referred cases for agreed upon period.The rates for tests and treatment would be charged as per approved list.2. The Hospital will not be at liberty to revise the rate suo moto.Treatment in Emergency3. In grave emergency, patient shall be admitted and life saving treatment be given onproduction of ECHS card by the members, even in the absence of referral slip. All emergencies willbe treated on cashless basis till stabilization even if the speciality concerned for management of thecase is not empanelled. The hospital will inform the nearest Polyclinic about the admission within 48hrs. Payments will NOT be recovered from ECHS patient in such cases. The following ailments maybe treated as an emergency which is illustrative only and not exhaustive, depending on thecondition of the patient :-(a) Acute Cardiac Conditions/Syndromes including Myocardial Infarction, UnstableAngina, Ventricular Arrhythmias, Paroxysmal Supraventricular Tachycardia, CardiacTamponade, Acute Left Ventricular Failure/ Severe Congestive Cardiac Failure, AcceleratedHypertension, Complete dissection.(b) Vascular Catastrophies including Acute Limb ischaemia, Rupture of aneurysms,medical and surgical shock and peripheral circulatory failure.(c) Cerebro-Vascular Accidents including Strokes, Neurological Emergencies includingComa, Cerebro meningeal infections, convulsions, acute paralysis, acute visual loss.(d)(e)Acute Respiratory Emergencies including Respiratory failure and decompensatedlung disease.Acute abdomen including acute obstetrical and gynecological emergencies.(f) Life threatening Injuries including Road traffic accidents, Head Injuries, MultipleInjuries, Crush Injuries and thermal injuries.(g)(h)(j)(k)Acute Poisonings and Snake bite.Acute endocrine emergencies including Diabetic Ketoacidosis.Heat stroke and cold injuries of life threatening nature.Acute Renal Failure.(l) Severe infections leading to life threatening sequelae including Septicemia,disseminated/miliary tuberculosis.

10Corrupt and Fraudulent Practices4. “Corrupt Practice” means the offering, giving, receiving or soliciting of anything of value toinfluence the action of the public official.5. “Fraudulent Practice” means a misrepresentation of facts in order to influence empanelmentprocess or a execution of a contract to the detriment of ECHS and includes collusive practiceamong hospitals/authorized representative/service providers.6. ECHS will suspend referrals if it determines that the hospital recommended for empanelmenthas engaged in corrupt or fraudulent practices and initiate process for dis-empanelment.Interpretation of the Clauses in the Application Document7. In case of any ambiguity in the interpretation of any of the clauses in Application Document,interpretation of Central Organisation ECHS of the clauses shall be final and binding on all parties.Right to Accept any Application and to Reject any or All Applications8. ECHS reserves the right to accept or reject any application at any time without therebyincurring any liability to the affected hospital/authorized representative/ service provider or anyobligation to inform the affected hospital/authorized representative/service provider of the groundsfor his action.Monitoring and Medical Audit9. ECHS reserves the right to inspect the hospitals at any time to ascertain their compliancewith the requirements of ECHS.10. Bills of hospitals shall be reviewed frequently for irregularities including declaration ofplanned procedures/ admissions as ‘emergencies’, unjustified investigations and prolonged stayetc., and if found involved in any wrong doings, the concerned hospital would be removed frompanel and black listed for future empanelment. Bank guarantee shall also be forfeited.Exit from the Panel11. The Rates fixed by the ECHS shall continue to hold good unless revised by ECHS. In casethe notified rates are not acceptable to the empanelled Private Hospital, or for any other reason, thePrivate Hospital no longer wishes to continue on the list of empanelled Private Hospitals, it canapply for exclusion from the panel by giving three months notice and by depositing an exit fee of Rs3000/- (Rupees Three thousand only) in the form of Demand Draft in favour of concerned RegionalCentre ECHS.Package Rates12. Package rate shall mean and include lump sum cost of inpatient treatment/ daycare/diagnostic procedure for which a ECHS beneficiary has been referred by the competentauthority or for treatment under emergency from the time of admission to the time of dischargeincluding (but not limited to) the following :-(a)(b)(c)(d)Registration charges.Admission charges.Accommodation charges including patients diet.Operation charges.

11(e)(f)(g)(h)(j)(k)(l)(m)(n)(o)(p)(q)(r)(s)Injection charges.Dressing charges.Doctor/Consultant visit charges.ICU/ICCU charges.Monitoring charges.Transfusion charges.Anaesthesia charges.Operation Theatre charges.Procedure charges/Surgeon’s fee.Cost of surgical disposables and all sundries used during hospitalization.Cost of medicines.Related routine and essential investigations.Physiotherapy charges etc.Nursing Care and charges for its services.13. Cost of implants/stents/grafts is reimbursable in addition to package rates as per ceilingrates of CGHS for Implants/stents/graft or as per actual, in case there is no CGHS prescribed ceilingrate.14. Treatment charges for new born baby are separately reimbursable in addition to deliverycharges for mother.15. The hospitals empanelled under ECHS shall not charge more than the package rates/lowerrates negotiated in MOA whichever is lower.16. Package rates envisage upto a maximum duration of indoor treatment as follows :-(a)(b)(c)(d)12 days for Specialised (Super Specialities) treatment.7 days for other Major Surgeries.3 days for Laparoscopic surgeries/normal deliveries.1 day for day care/minor (OPD) surgeries.17. However, if the beneficiary has to stay in the hospital for his/her recovery for a period morethat the period covered in package rate, in exceptional cases, supported by relevant medicalrecords and certified as such by hospital, the additional reimbursement shall be limited toaccommodation charges as per entitlement, investigations charges at approved rates and doctorsvisit charges (not more than 2 visits per day by specialists/consultants) and cost of medicines foradditional stay.18. No additional charge on account of extended period of stay shall be allowed if that extensionis due to infection on the consequences of surgical procedure or due to any improper procedure andis not justified.

1219. The package rates are for semi-private ward. If the beneficiary is entitled for generalward there will be a decrease of 10% in the rates. For private ward entitlement there will be anincrease of 15%. However, the rates shall be same for investigation irrespective of entitlement,whether the patient is admitted or not and the test per se does not require admission to hospital.20. A hospital empanelled under ECHS whose normal rates for treatment procedure/test arelower than ECHS prescribed rates shall charge as per the rates charged by them for thatprocedure/treatment from a non ECHS beneficiary and will furnish a certificate to the effect that therates charged from ECHS beneficiaries are not more than the rates charged by them from nonECHS beneficiaries.21. During In-patient treatment of the ECHS beneficiary, the hospital will not ask the beneficiaryor his/her attendant to purchase separately the medicines/sundries/ equipment or accessories fromoutside and will provide the treatment within the package rate, fixed by the ECHS which includes thecost of all the items.22. If one or more minor procedures form part of a major treatment procedure, then packagecharges would be permissible for major procedure and only at 50% of charges for minor procedure.Entitlement of Wards23. ECHS beneficiaries are entitled to facilities of private, semi-private or general warddepending on their Rank at the time of retirement. The entitlement is as follows:-Ser Rank at the time of Retirement Entitlement(a) NCOs & below of Army & equivalent in Navy & Air General WardForce(b) JCOs in Army & equivalent in Navy & Air Force Semi Private Ward(c) Officers of Army, Navy and Air Force Private WardIndemnity24. The hospital shall at all times, indemnity and keep indemnity ECHS/the Government againstall actions, suits, claims and demands brought or made against it in respect of anything done orpurported to be done by the Hospital in execution of or in connection with the services under thisAgreement and against any loss or damage to ECHS/the Government in consequence to any actionor suit being brought against the ECHS/the Government, alongwith (otherwise), Hospital as a Partyfor anything done or purported to be done in the course of the execution of this Agreement. Thehospital shall at all times abide by the job safety measures and other statutory requirementsprevalent in Indian and shall keep free and indemnify the ECHS from all demands orresponsibilities arising from accidents or loss of life, the cause or result of which is the hospitalnegligence or misconduct.25. The hospital shall pay all indemnities arising from such incidents without any extra cost ofECHS and shall not hold the ECHS responsible or obligated. ECHS/the Government may at itsdiscretion and shall always be entirely at the cost of the hospital defend such suit, either jointly withthe hospital or singly in case the latter chooses not to defend the case.Documents to be Submitted26. Copies of the following documents are to be attached alongwith the application :-(a)Copy of certificate or memo of State Health authority, if any recognizing the Hospital.(b) Copy of audited balance sheet, profit and loss account for the last three years (Maindocuments only – summary sheet).

13(c) Copy of legal status, place of registration and principal place of business of thehospital or partnership firm, etc.(d)A copy of partnership deed/memorandum and articles of association, if any(e) Affidavit of sole proprietorship on non-judicial stamp paper if medical facility is ownedby individual.(f) Copy of Customs duty exemption certificate and the conditions on which exemptionwas accorded.(g)(h)Photocopy of PAN Card.Name and address of their bankers.(j) Copy of the existing list of rates approved by the Hospital for variousservices/procedures being provided by it.(k) Registration Certificate under PNDT Act in case of Centres applying forUltrasonography facility.(l)Copy of the license for running Blood bank.(m) Copy of certificate of NABH Accreditation with Scope of Accreditation duly notarisedif NABH accredited facility.(n) Copy of NABL Accreditation with Scope of Accreditation duly notarised if NABLaccredited facility.(o) Copy of CGHS office memorandum regarding the empanelment of the medicalfacility with CGHS and Valid MoA with CGHS, if CGHS empanelled medical facility.Note : Applications not containing the above particulars shall not be considered for empanelment.27. Certificate of Undertaking. In addition a certificate given below will be rendered by theHead of the Institution and attached with the application.CERTIFICATE OF UNDERTAKING1. It is certified that the particulars regarding physical facilities and experience/expertise ofspecialty are correct.2. That Hospital shall not charge higher than the CGHS notified rates or the rates charged fromnon-CGHS patients.3. That the rates have been provided against a facility/procedure actually available at theinstitution.4. That if any information is found to be untrue, Hospital be liable for de-recognition by CGHS.The institution will be liable to pay compensation for any financial loss caused to CGHS or physicaland or mental injuries caused to its beneficiaries.5. That all Billing will be done in electronic format and medical records will be submitted indigital format.6. That the Hospital has the capability to submit bills and medical records in digital format.7. That Hospital will allow a discount of 10% on payment that are made within seven days fromthe date of submission of the bill to ECHS.

148. The Hospital will pay damage to the beneficiaries if any injury, loss of part or death occursdue to gross negligence.9. That the centre has not been derecognized by CGHS or any state Government or otherOrganization, after being empanelled.10. That no investigation by Central Government/State Government or any StatuaryInvestigating agency is pending or contemplated against the hospital.SignatureHead of Institution/Authorized Signatory28. Certificate for Acceptance of Rates. A certificate given below will also be renderedby the Head of the Institution and attached with the application :-CERTIFICATE FOR ACCEPTANCE OF RATES1. It is certified that _______________________________________ (name of the institution /hospital) shall abide by ECHS rates promulgated from time to time and in no case shall the ratescharged be in excess of those normally charged to non-ECHS members.2. It is further certified that on approval for empanelment the hospital/institution shall negotiateand accept rates lower or equal to prevailing ECHS rates.SignatureHead of Institution/Authorized Signatory29. Check list for documents must be filled, signed by authorised signatory of the medicalfacility, checked and countersigned by Director, Regional Centre where applicable be submittedwith application form. Check list is enclosed as Annexure to empanelment application.

15SECTION IIAPPLICATION FORMAT FOR HOSPITALSPART 1GENERAL INFORMATION(Technical and Infrastructure Specifications of the Hospitals)1. NABH Accreditation Status(a) Whether NABH Accredited(b) Pre-accredited entry level2. Details of Accreditation and Validity period …………………………………………………………(enclose a scanned copy of relevant Certificate) ……………………………………………………….3. Name of the Station Headquarters / Regional Centre under whose AOR the hospital is located(a) StnHQ(b) RC4. Name of the hospital5. Address of the hospitalContact person & Designation6. Tele/Fax/E-mailTelephone NoFaxE-mail/website address7. Details of Application Fee (MRO) and EMD (Bank Guarantee) :-MROEMD (Bank Guarantee)Number & Bank ……………………… ………………………………………Date: …………………….. ………………………………………SIGNATURE OF THE AUTHORIZED APPLICANT

16PART II: BACK GROUND INFORMATIONSer SubjectNo1. Historical BackgroundDate of EstablishmentRegistered/Not Registered*(with State Health Authorities)Information givenby HospitalRemarks ofQCI (NABH)Type-Govt/Private/CorporateManagement(Individual/Corporate/Trust or any other– please specify)Recognition by other schemes –CGHS/Rlys/Public Schemes* - indicatewhich schemes are you linked with.Already empanelled with ECHS –Yes/No2. LocationDistance from nearest ECHS PolyclinicAvailability of public transportDistance from Railway station/Busstand/Airport 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 INFORMATIONSer SubjectNo1. Hospital InformationBuildingTotal AreaInformation given byHospitalRemarks ofQCI (NABH)Floor AreaTotal Number of Beds in HospitalMacro 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 be included.2. Miscellaneous (Specify) – You may include any other pertinent details, you feel necessary.SIGNATURE OF THE AUTHORIZED APPLICANT

3. Total number of beds18Remarksof QCI(NABH)4. Categories of beds available with number of total beds in following wards :-(a) Casualty/Emergency ward(b) ICCU/ICU (4-12 beds)(c) Private Ward(d) Semi-Private ward (2-3 bedded)(e) General ward bed (4-10 bedded)(f) Total Area of the Hospital (1.5 Hectare or 4 Acres) :-(i) Area allotted to OPD(ii) Area allotted to IPD(iii) Area allotted to Wards5. Specifications of beds with physical facilities/amenities :-Dimension ofward lengthbreadth categoryNumber of bed ineachSq MtFurnishing floorarea per patientAmenities(Seven Square Meter Floor area per bed required) (IS:12433-Part 2:2001)General Ward (4-8 beds)Semi Private Ward (2-3 beds)Private Ward (Single bed withattendant bed)6. Nursing Care :-(a)(b)Total number of NursesNo of para-medical staff(c) Category of Bed Bed/Nurse Ratio Actual Bed/Nurse(Acceptable Standard) Ratio General 6 : 1 Semi-Private 4 : 1 Private 4 : 1 ICU/ICCU 1 : 1 High Dependency Unit 1 : 1SIGNATURE OF THE AUTHORIZED APPLICANT

197. Alternate power source Yes No8. Bed occupancy rate (Norm 85%) Bed Turn Over rateRemarksof QCI(NABH)(a)(b)(c)General BedSemi-Private BedPrivate BedNote : Bed Occupancy rate = Av daily census * 100Av No of bed available(i.e No of authorized bed)Turn over ratio = Total discharge during a yearBed compliment(No of authorized bed)9. No of In house Doctors10. No of In house Specialist/Consultant11. No of visiting specialist/Consultant(Names and qualifications)Attach separate sheet if necessary12. Laboratory facilities available :-(a)(b)(c)PathologyBiochemistryMicrobiology(d) Any other(Statistics for the last three years)(Essential facility required for services being provided should be available)13. Imaging facility available (Statistics for the last three years)(Essential facility required for services being provided should be available)14. Supportive Services :-(a)Boilers/Sterilizers(b) Ambulance (Basic Life Support System Ambulances)(c)LaundrySIGNATURE OF THE AUTHORIZED APPLICANT

20)(d)(e)HousekeepingCanteenRemarksof QCI(NABH)(f)Gas plant(g)Waste disposal system as per prescribed rules(h)Dietary15. Others (Preferably) :-(a)(b)(c)(d)Blood BankPharmacyPhysiotherapyNo of Operation TheatreSIGNATURE OF THE AUTHORIZED APPLICANT

21PART IV: FACILITIES APPLIED FOR1. Application for Empanelment as :-General Purpose HospitalSpeciality HospitalSuper-Speciality HospitalCancer HospitalPhysiotherapy CentresRehabilitative Centres and HospicesPrivate hospitals already on the panel of ECHSSHCO/Nursing Home/Allopathic Clinic(Please select the appropriate columns)2. Total number of beds3. Facilities Applied.(a)General Purpose Hospital.(i) General Medicine(ii) General Surgery(iii) Obstetrics and Gynecology(iv) Paediatrics(v) Orthopedics (excluding Joint Replacement)(vi) ICU and Critical Care units(vii) ENT(viii) Ophthalmology(ix) Imaging facilities(x) Blood Bank(xi) Dermatology(xii) Psychiatry(xiii) Dental(xiv) Pathology (Biochemistry, Microbiology, Serology,Immunology, Haematology, Histopathology, etc)(xv) Others (if any)Remarksof QCI(NABH)SIGNATURE OF THE AUTHORIZED APPLICANT

22(b)Specialty Hospitals.(i)(ii)Cardiology, Cardiovascular and Cardiothoracic surgeryUrology – including Dialysis and LithotripsyRemarksof QCI(NABH)(iii) Orthopedic Surgery – including arthroscopic surgeryand Joint Replacement(iv)(v)(vi)(vii)Endoscopic SurgeryNeuro SurgeryNeuro MedicineGastro-enterology(viii) Endocrinology(ix)(x)(xi)(xii)(xiii)(xiv)(xv)(xvi)RheumatologyClinical HaematologyMedical OncologyRespiratory DiseasesCritical Care MedicineMedical GeneticsRadiotherapyNuclear Medicine(xvii) Plastic and Reconstructive Surgery(xviii) Vascular surgery(xix)(xx)(xxi)Paediatric surgeryOnco SurgeryGI Surgery(xxii) Traumatology(xxiii) Prosthetic Surgery(xxiv) Gynecological OncologySIGNATURE OF THE AUTHORIZED APPLICANT

23(xxv) Fertility and Assisted Reproduction(xxvi) Neonatology(xxvii) Paediatric Cardiology(xxviii)Haematology and Oncology(xxix) Onco-pathology(xxx) Transfusion Medicine(xxxi) Interventional and Vascular Radiology(xxxii) Specialised Dental Procedures (Oral Maxillo FacialSurgery, Orthodontia, Prosthodontia, Periodontia,Endodontia, Paedodontia, ________________)(xxxiii)Others (if any)Remarksof QCI(NABH)(c)Super Speciality Hospital.(i) Cardiology(ii) Cardiothoracic Surgery(iii) Specialised Orthopedic Treatment facilitiesthat include Joint Replacement surgery(iv) Nephrology and Urology(v) Endocrinology(vi) Neurosurgery(vii) Gastroenterology and GI surgery(viii) Oncology(ix) Organ Transplant (Liver/Kidney/Renal/Others)(x) Others (if any)Remarksof QCI(NABH)(These hospitals shall provide treatment/services in all disciplines available in the hospital)(d)Cancer Hospitals.Remarks of QCI (NABH)SIGNATURE OF THE AUTHORIZED APPLICANT

24PART V: INFORMATION ON PROFESSIONAL SERVICES1. EMERGENCY SERVICES: (Mandatory for all General/MultiSpeciality Hospitals)Remarksof QCI (NABH)(a)Emergency Services – Available/Not available(If available average number of emergencies per month)(b)Staffing(i)(ii)(iii)Duty Doctors – Number on DutyNursing Staff – Nurses on DutyConsultants – Present – If Present, then specialityOn call – If on call, time taken byConsultant(c)Equipment available (indicate make, type & vintage of eqpt)(i)(ii)(iii)(iv)(v)(vi)(vii)Monitor defibrillatorsNebulisersInfusion PumpsPulse OximeterOxygen supply (define arrangement)Suction apparatusVentilator(viii) Others specify(d)MiscellaneousSIGNATURE OF THE AUTHORIZED APPLICANT

252. INTENSIVE CARE UNIT: (Mandatory for all Multi SpecialityHospitals)(a) Intensive Care Unit – Available/Not AvailableSpecialised Intensive Care Units – Specify AvailabilityRemarksof QCI(NABH)(i)(ii)(ii)CardiacNeurologicalOthers – give details(b)Staffing(i)(ii)(iii)Duty Doctors – Number on DutyNursing Staff – Number and Specialised NursesConsultants – Present – If present, then specialityOn call – if on call, time taken byConsultant(c)Equipment available (Indicate make, type & vintage of eqpt)(i)(ii)(iii)(iii)(iv)(v)(vi)(vii)Monitor defibrillatorsNebulisersInfusion PumpsPulse OximeterOxygen supply (piped and cylinders/concentrator etc)Suction apparatusVentilatorOthers specify(d)Utilisation Indices(i)(ii)Bed occupancyNurse Bed ratio(e)(i)(ii)ICU/ ICCU chargesBed Charges of ICU (excluding consultation/treatment)Bed Charges for Specialised intensive care unitsSIGNATURE OF THE AUTHORIZED APPLICANT

263. OPERATION THEATRES (Mandatory for all hospital withSurgical facilities)(a)Operation Theatre – Available/Not availableNumber of Operation Theatres-Remarksof QCI(NABH)(i)(ii)General SurgerySpecialised Procedures(The specialized features for special OTs eg. JointReplacement, Cardio thoracic & NeurosurgeryShould be specified.(b)Staffing(i)(ii)Number of Anaesthetists -Number present(attach list with -Number on DutyQualifications) -Number on Call-Number on PermanentRoll-Number of Visiting-AnaesthetistsOperating Theatre Staff-OT Matrons and Nurses-OT Technicians(c)(d)Equipment- Specify major Equipment(Indicate make, type & vintage of eqpt)OT Services(i) CSSD - Available/Not AvailableType of sterilization techniques(ii)Sterlisation of OT• Frequency• Method(iii)Oxygen supply (piped/cylinders/concentrator etc)(e)(iv) OT Environment• Air Conditioning - Type• Laminar Flow – Yes/NoUtilisation Indices(i) Average Number of Surgeries underGA in last 4 months(ii) Type of Surgeries (Mention Speciality)SIGNATURE OF THE AUTHORIZED APPLICANT

27PART VI - GENERAL SERVICES(Note : For General Purpose Hospitals provide the following details. Please use separate sheetsof paper for each General Speciality. Attach list of consultants, equipment and utilizationindices pertaining to the specialised services alongwith the sheet). Emergency services,Intensive Care Unit and Operation Theatre details are mandatory to be filled in the samedocuments.(a) Name of Speciality -…………………………………………………………………(b)Utilisation Indices & Statistics(i)Out Patient Services• Days and timing of OPD ………………………………………….• Appointment facility – Available/Not Available• Workload per month - ………………………………………………(ii)In Patient Services• Availability of Beds for the Speciality - Yes/No(If Yes specify number of Beds)• Nurse Patient ratio• Resident Doctor Available - Yes/No• Emergency Services for the Speciality - Available/Not Available(iii)Surgeries/Procedures• Number of Surgeries under GA per month• Minor procedures/Surgery per month(c)Staffing(d)(i) Consultants - Total number of Consultants- Number of Consultants on Permanent Roll- Number of Visiting Consultants to facility(Attach list of the consultants and qualifications and experiencedetailing whether consultant is on permanent roll or visiting)(ii) Nursing Staff - Total number of staff nurses- Specialty trained nurses(iii) Others (Specify) – Special Technical StaffEquipment – Specify major equipment if present. (Indicate make, type &vintage of eqpt(i) ……………………………………………………………………(ii) ……………………………………………………………………(e) Package Rate – (Specify)Remarks of QCI (NABH)SIGNATURE OF THE AUTHORIZED APPLICANT

28PART VII – SPECIALISED SERVICES(Note : For every Specialised Services offered for empanelment provide the following details.Please use separate sheet of paper for each Specialised Service. Attach list of consultants,equipment and utilisation indices pertaining services alongwith the sheet.)(a)(b)Type of Specialised Service - …………………………………………………………Utilisation Indices & Statistics(i)Out Patient Services• Days and timing of OPD -………………………………………………• Appointment facility – Available / Not Available.• Workload per month -…………………………………………………….(ii)Inpatient Services• Availability of Beds for the Speciality – Yes/No• Nurse Patient ratio• Resident Doctor available – Yes / No• Emergency Services for the Speciality – Available/Not Available(iii)Surgeries / Procedures(c)• Number of Surgeries under GA per month• Minor procedures / Surgeries per monthStaffing(i) Consultants - Total number of Consultants- Number of Consultants on Permanent Roll- Number of Visiting Consultants to facility(Attach list of the consultants and qualifications andexperience detailing whether consultant is onpermanent roll or visiting)(ii) Nursing Staff - Total number of staff nurses.- Speciality trained nurses.(e)(f)(iii) Others (Specify) - Special Technical StaffMajor Specialised Tests/Procedures Available (attach list)Package Rates – (Specify)Remarks of QCI (NABH)SIGNATURE OF THE AUTHORIZED APPLICANT

29PART VIII: ADDITIONAL INFORMATIONSPECIALISED TESTS/TREATMENT(AS APPLICABLE)1. MRI(a)ManufacturersEquipment particularsModelName ofDate of InstallationTeslaTo be filled by theHosp/DiagnosticCentreRemarks ofQCI (NABH)(b)Utilisation StatisticsNumber of MRI done in last yearTotal Billing on MRI during last one year(c)Qualification(i) Qualified Radiologist withminimum 3 years post degreeexperience.(ii)Technicians – Full Time, holding degree/ diploma (2 years) from recognizedinstitutions.2. CT SCAN(a) Equipment Particulars :-To be filled by theHosp/DiagnosticCentreRemarks ofQCI (NABH)(i)(ii)(iii)(iv)ModelName of manufacturesDate of InstallationVintage of CT Scan Machine(b) Slices per secondEquipment for resuscitation of patientslike Boyle’s apparatus, suction machines,emergency drugs to combat any allergicreactions due to contrast medium.(c)Utilisation Statistics(i) No of CT scan done in lastyear(ii) Total billing on CT Scanduring last one yearSIGNATURE OF THE AUTHORIZED APPLICANT

30(d)Qualification(i) Qualified Radiologist withminimum 3 years post degree experience.To be filled by theHosp/DiagnosticCentreRemarks ofQCI(NABH)(ii) Qualified Radiographer –Holdingdiploma(2 years)/degree in Radiography fromrecognizedinstitutions.(iii) Provision of nursing staff/femaleattendant for lady patients.(e)Legal compliance(Housed in building as per AERB guidelines,Provision of Radiation Protective Devicelike Screen, Lead Apron, Thyroid and Gonadsprotective shield)3. USG/COLOUR DOPPLER CENTRE FACILITY AVAILABLE : Yes/No(a)Equipment particularsModelName of ManufacturersDate of InstallationHigh resolution USGMchineTo be filled bytheHosp/DiagnosticCentreRemarks ofQCI (NABH)(b)Qualification(i) Qualified Radiologist withminimum 3 years post degree experience.(ii) Full time nurse/female attendantfor female patients(c)Legal compliance(Registration under the PNDT Act and itsstatus of implementation)4. OTHER SPECIALISED INVESTIGATIONS(a)yearNumber of Mammography in last oneTo be filled by theHosp/Diagnostic CentreRemarks ofQCI (NABH)(b) Number of Bone densitometryinvestigation in last one year.SIGNATURE OF THE AUTHORIZED APPLICANT

5. CARDIOLOGY(a)year(b)31Number of angiogram done in last oneNumber of Angioplasty in last one year(c) Are qualified cardiologist with DMdegree available on regular employment.(d) Whether the hospital has asepticOperation Theatre for Cardiology Surgery(e) Whether, it has required instrumentationfor Cardiology Surgery (Angiogram &Angioplasty)To be filled by theHosp/DiagnosticCentreRemarks ofQCI (NABH)6. CARDIO – THORACIC SURGERY(a)(b)(c)(d)(e)Number of Open heart surgery done in last oneYear (Minimum – 400/Year)Number of CABG done in last one year(Minimum 200/year)Qualified Cardiothoracic Surgeon available onregular employmentWhether the hospital has aseptic OperationTheatre for Cardio-Thoracic SurgeryWhether, it has required instrumentation forCardio-Thoracic Surgery7. NEURO SURGERY(a)(b)(c)(d)Number of major Neuro Surgeries does in the donein the last one yearAre qualified Neurosurgeon with minimum 5 yearsexperience available on regular employmentWhether the hospital has aseptic OperationTheatre for Neuro SurgeryWhether it has required instrumentation forNeurosurgery(e) Whether EEG facilities available ?(f) Whether CT Scan available ?(g) Facility for Gamma Knife Surgery available ?(h)Facility for Trans-sphenoidal endoscopic available?(j) Facility for Steriotactic surgery available ?To be filled by theHosp/DiagnosticCentreTo be filled bytheHosp/DiagnosticCentreRemarks ofQCI (NABH)Remarks ofQCI(NABH)SIGNATURE OF THE AUTHORIZED APPLICANT

328. JOINT REPLACEMENT SURGERY(a) Number of major Joint Replacement surgeries donein last one year.To be filled bytheHosp/DiagnosticCentreRemarks ofQCI (NABH)(b)(c)Are qualified Orthopaedic Surgeon withMCH/MSC (Liverpool/MSC London) orspecialised training in recognised centresfor joint replacement available on regularemployment.Aseptic Operation Theatre Present (Yes/No)(d) Required instrumentation for Knee/HipReplacement(e)Nursing barrier for isolation of patient9. LAPAROSCOPIC SURGERY(a)Number of Laparoscopic Surgery in last one yearTo be filled bytheHosp/DiagnosticCentreRemarks ofQCI (NABH)(b)(c)(d)Percentage of patients requiring conventionalsurgery due to failure of laparoscopic surgeryAre qualified Surgeon trained in Laparoscopicsurgery with sufficient experience availableAseptic Operation Theatre Present(e) The hospital has at least one complete set ofLaparoscopic/Endoscopic equipment and instruments withaccessories and should have facilities for open surgeru i.eafter conversion from Laparoscopic/Endoscopic surgerySIGNATURE OF THE AUTHORIZED APPLICANT

10. LITHOTRIPSY/TURP, OTHER NEPHROLOGY/UROLOGY PROCEDURES33(a)yearNumber of major surgeries in last oneTo be filled by theHosp/DiagnosticCentreRemarks ofQCI (NABH)(b) Number of cases treated by Lithotripsy inlast one year(c) Percentage of cases selected forlithotripsy which required conventional surgery(d) Qualified Uro Surgeon with MCH degreeavailable(e) Aseptic Operation Theatre Present11. RENAL TRANSPLANTATION, HEMODIALYSIS(a)Renal Transplantation(i)Number of Renal Transplant inlast one yearTo be filled by theHosp/DiagnosticCentreRemarks ofQCI (NABH)(ii)(iii)(iv)Qualified Uro Surgeon with MCHdegree availableIf the Hospital is recognised byIndian Society of Nephrology.Immunology lab present or not(b)(v) Blood transfusion facilitiesPresent or not(vi) Tissue typing unitDTPA/IMSA/DRCG present or not(vii) Scan facility available/notavailable(viii) Radiology facility available/not availableTo be filled by theHosp/DiagnosticHaemodialysis unitCentre(i) Number of Dialysis carried out permonth(ii) Centre has trained DialysisTechnical and Sisters and full timeNephrologists and Resident Doctors availableto combat the complications during the Dialysis.(iii)(iv)Number of Dialysis machine in unitRemarks ofQCI (NABH)Date of establishment of unitSIGNATURE OF THE AUTHORIZED APPLICANT

3412. LIVER TRANSPLANTATIONTo be filled by theHosp/DiagnosticCentreRemarks ofQCI (NABH)(a)(b)(b)(d)(e)(f)(g)Number of Liver Transplant done in lastone yearDate and year when the Liver Transplantprogramme commencedSuccess rate of Liver Transplantqualified Gastroenterologist or GISurgeon available technical expertise inLiver Transplantation (atleast 50 livertransplantsFacilities for transplant immunology labTissue typing facilitiesBlood BankRadio Diagnosis(h)Rates:-Sl No. ProcedureLiver Transplantation1 Liver Transplantation RecipientAveragelengthof stayin daysPackagecostofferedtoGeneralPublicPackagecostofferedtoECHSRemarksofQCI(NABH)2 Liver Transplantation DonorSIGNATURE OF THE AUTHORIZED APPLICANT

3513. RADIOTHERAPYTo be filled by theHosp/DiagnosticCentreRemarks ofQCI (NABH)(a) Number of Liver Transplant done in lastone year(b) Qualified Radiotherapist with MD degreein radiotherapy and 3 years experience.(c)(d)Medical PhysicianCobalt UnitDate of installation of unitPatient load per day(e)Linear AcceleratorDate of installation of unitPatient load per day(f)BrachytherapyDate of installation of unitPatient load per day(g)IMRTDate of installation of unitPatient load per daySIGNATURE OF THE AUTHORIZED APPLICANT

36PART IX – LABORATORY SERVICES(For every Laboratory Service offered for empanelment provide the following details).1. Type of Laboratory Service - …………………………………………………………….(Specify services for Hematology, Biochemistry, Microbiology, Immunology etc)2. Services - Inhouse/Outsourced3. Laboratory Statistics(a) Timing of sample collection - …………………………………………………(b)Workload- Clinical Path -- Biochemistry -- Micro biology -- Others (specify) -(c) Emergency Services - Available/Not Availabe1(d) Staffing(i) Consultants - Total number of Consultants- Number of Consultants on Permanent Roll- Number of Visiting Consultants to facility(Attach list of the consultants and qualifications and experience detailing whetherconsultant is on permanent roll or visiting)(ii) Lab Technicians - Total number- Specialty trained nurses(iii) Others (specify) - Special Technical Staff(e) Equipment- Specify major equipment if present (attach list) (Indicate make, type &vintage of eqpt)(i)…………………………………………………………………………………………(ii)………………………………………………………………………………………(f)Quality Audits(i)(ii)Internal Audit.External Audit.(g)Package Rate- (Specify)Remarks of QCI (NABH)SIGNATURE OF THE AUTHORIZED APPLICANT

37PART X – RADIO DIAGNOSIS & IMAGING SERVICES(For every Radio Diagnosis and Imaging Services offered for empanelment provide thefollowing details. Use separate sheets for each service viz X ray, CT scan, MRI etc)1. Type of Radio Diagnosis and Imaging Services-……………………………………………(Specify services for X Ray, Contrast studies, Ultrasound, CT Scan and MRI etc)2. Services - Inhouse/Outsourced3. Statistics(a) Working Hours - ………………………………………………………(b)Workload per day• X-ray -• Ultrasound -• Mammography -• CT Scan -• MRI -• Others (specify) -(c) Emergency Services - Available/ Not Available(d)Staffing(i) Consultants - Total number of Consultants- Number of Consultants on Permanent Roll- Number of Visiting Consultants to facility(Attach list of the consultants and qualifications and experience detailing whetherconsultant is on permanent roll or visiting)(ii) Lab Technicians - Total number- Specialty trained nurses(iii) Others (specify) - Special Technical Staff(e) Equipment- Specify major equipment if present (attach list) (Indicate make, type &vintage of eqpt) (For MRI- mention Tesla grading)(f)(i)……………………………………………………………………………………(ii)……………………………………………………………………………………Misc Issues(i)(ii)Radiological safety measures.Ultrasound registration (Attached copy of PNDT Certificate).(g) Package Rate- (Specify)Remarks of QCI (NABH)SIGNATURE OF THE AUTHORIZED APPLICANT

38PART XI – BLOOD BANK(For Blood Bank Services offered for empanelment provided the following details)1. Services - In-house/Outsourced.It outsourced, to whom outsourced - ……………………………………………………………………………………………………………………………………………………………(Columns below are to be filled for in house or outsourced facility)2. Statistics(a) Blood Testing facility - Available/ Not available(b)WorkloadPer day - …………………………………………….Per month - .……………………………………………(c)Emergency Services – Available/Not Available3. Staffing(a)(b)(c)………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………4. Equipment – Specify major equipment if present (attach list) (Indicate make, type & vintageof eqpt)(a)(b)……………………………………………………………………………………………………………………………………………………………………………………5. Misc Issues(a)Registration number/License number (attach copy of authority)6. Package Rate – (Specify)……………………………………………………………………………………………………………………………………………………………………………………………………………………Remarks of QCI (NABH)SIGNATURE OF THE AUTHORIZED APPLICANT

39PART XII – ANCLILLARY SERVICESRemarks ofQCI (NABH)1. House keeping services(a)(b)(c)(d)(e)General cleanliness of hospital OPD wards.Cleanliness of rooms.Cleanliness of toilets.Number of Staff available.Frequency of cleaning.2. Hospital waste Management(a)(b)Conformity of RulesAvailability of adequate collection and disposal system.3. CSSD – Available/Not Available(a)Method of sterlisation4. Pharmacy(a)(b)(c)(d)In house/contractMedicines available in hospital/procured from outsideBilling system – Computerised/Manual.Responsibility for procuring medicines under package deal• Hospital• PatientSIGNATURE OF THE AUTHORIZED APPLICANT

405. Legal Issues(a)(b)Conformity to various Acts/Rules & RegulationsPast history of cases (03 years) under COPRA/MedicalNegligence/Criminal Law(i)(ii)(iii)Pending in courtsJudgment in favour of HospitalJudgment against Hospital(c)Additional Acts/Rules where applicable(iv)(v)(vi)(vii)MTP ActOrgan transplant ActDrug and Cosmetic ActUltrasound registration(viii) Blood Bank Regn(ix)Others (Specify)6. Hospital Utilisation Indices(a)(b)(c)(d)(e)(f)(g)Bed occupancy RateAverage length of stayAverage daily OPD attendancesGross death rateNet death ratePost operation Mortality rateCaesarian rate7. Does the facility accept HIV/AIDS patients – Yes / NoSIGNATURE OF THE AUTHORIZED APPLICANT

41SECTION IIIINSPECTION REPORT AND RECOMMENDATIONS OF QCI (NABH)Recommendations of the QCI (NABH)1. ………………………………………………………………………………………..(Name ofHospital/ Nursing Home/Diagnostic Centre/Hospice) is recommended/not recommended forempanelment for Ex-Servicemen Contributory Health Scheme (ECHS) for service offered by theinstitution.2. The Specialities of ………………………………………………………………………..(Name of Hospital / Nursing Home/Diagnostic Centre/Hospice) listed in the table below arerecommended/not recommended for empanelment for Ex-Servicemen Contributory Health Scheme(ECHS).(Note : Mention R for Recommended and NR for Not Recommended. Strike out specialities notoffered for empanelment with an X)(a) General ServicesType of Speciality Type of Speciality Type of SpecialityGeneral Medicine General Surgery Obstetrics andGynaecologyENT Opthalmology PaediatricsDental Psychiatry DermatologyMicrobiologyBlood Bank (BloodPathologytransfusion)OrthopaedicsRadio Diagnosis(b) Specialised ServicesSpecialised Services Specialised Services Specialised ServicesSurgery Medicine Obstetrics andGynaecologyNeuro Surgery Neuro Medicine GynaecologicalOncologyPlastic and ReconstructiveSurgeryCardiology (consultationand diagnostics)Infertility andAssisted ReproductionCardio Thoracic SurgeryInterventional CardiologyVascular SurgeryGastro enterologyGenito Urinary Surgery Endocrinology PaediatricsPaediatric Surgery Nephrology NeonatologyOncology (Surgery) Rheumatology CardiologyGastro Intestinal Surgery Clinical Haematology HaematologyTraumatology Oncology (Medical) OncologyJoint Replacement SurgeryCritical Care MedicineProsthetic Surgery Respiratory Diseases PathologyLaparoscopic Surgery Medical Genetics Onco pathologyRadiotherapyTransfusion MedicineNuclear MedicineTransplant PathologyRadio Diagnosis & ImagingOthers (Specify)CT ScanMRIInterventional and VascularRadiologySeal 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

Ser Name of Documents Applicable(Yes/No)16. REGISTRATION CERTIFICATE UNDER PNDT ACT(FOR US FACILITY)17. COPY OF LICENSE (FOR BLOOD BANKFACILITY)/IF OUTSOURCED – UNDERTAKINGAND LICENSE OF OUTSOURCED BLOOD BANK18. COPY OF NABH ACCREDITATION CERTIFICATEWITH SCOPE OF ACCREDITATION ATTESTEDBY NOTARY PUBLIC (FOR NABH ACCREDITEDHOSPITAL)19. COPY OF NABL ACCREDITATION CERTIFICATEWITH SCOPE OF ACCREDITATION ATTESTEDBY NOTARY PUBLIC (FOR NABL ACCREDITEDLABS/DIAGNOSTICS CENTRE)20. COPY OF CGHS OFFICE MEMORANDUM FORCGHS EMPANELLED MEDICAL FACILITIESDULY SIGNED BY AUTHERISED SIGNATORY21. COPY OF MOA WITH CGHS DULY SIGNED BYAUTHERISED SIGNATORY22. CERTIFICATE OF UNDERTAKING AS PER PARA27 OF TERMS AND CONDITIONS OFAPPLICATION FORM.23. CERTIFICATE OF ACCEPTANCE OF RATES PARA28 OF TERMS AND CONDITIONS OFAPPLICATION FORM.Note :-Attached(Yes/No)-2-Validity ofCertificatesIf attached thenpage numberFrom ToRemarks1. If any of the certificates mentioned in Sl No 01 to 23 is not applicable to any applicant medical facility, a certificate to that effect to be attached. The Check List &certificates to be countersigned by authorized signatory.2. Director, Regional Centre ECHS to scrutinise the Check List with the application and authenticate it. Remedial action, if any, to be taken before forwarding to CentralOrganisation ECHS.