Provider Information Sheet

NAME of Provider:TYPE:

HOSPITAL / NURSING HOME / EYE CENTER / CLINIC / DIAGNOSTIC CENTER / OTHERS

LEVEL OF CARE:

PRIMARY / SECONDARY / TERTIARY / SINGLE SPECIALITY/SUPERSPECIALITY

ADDRESS :Distric:STD Code:E MAIL :-

CITY :-

STATE :-

PIN NO.:FAX NO. :WEBSITE :-

TEL NO.

Landmark:City Grade
Mobile No.:-

NUMBER OF BEDS :PLOT SIZE (IN SQ. Mts.)

BUILT UP AREA(IN SQ. Fts.)

NAME OWNER / CONTACT PERSON / Medical Suprintendent:OUALIFICATION :E MAIL ID

TEL NO.

SPECIALITY :FAX NO. :-

Mobile No.:-

TEL NO.

E-MAIL ID:
FAX NO. :-

Mobile No.:-

TEL NO.

E-MAIL ID:
FAX NO. :-

Mobile No.:-

KEY CONTACT PERSON FOR TPA

KEY CONTACT PERSON BILLING

STAFF DETAILS:
NO. OF RESIDENT MEDICAL OFFICERS
NO. OF NURSING STAFFS

NO. OF FULL TIME CONSULTANTS

NO. OF OT TECHNICIANS

Google Map:
Longitude
Google Path

Latitude

Name & details of Hospital Information System

IS THE HOSPITAL / NURSING HOME REGISTERED WITH LOCAL AUTHORITY?
IF "YES" THEN REGISTRATION NUMBER :ISSUING AUTHOURITY :QUALITY CERTIFICATIONS (ISO / NABL / JCI):

No. of Doctors for OPD services

Please provide the details as per Annexure A

Yes

No

Yes

No

Yes

No

If yes -please provide the details as per Annexure B

Do you have Cafeteria

If yes -please specify the name of vendor

Do you have Book , Toy & Flower shop

If yes -please specify the name of vendor

NO

YES

NO

Place Of Registration

*HAS THE HOSPITAL EVER SUSPENDED FOR CASHLESS FACILITIES BY ANY TPA / INSURER ?
(IF YES, provide name of TPA / INSURER , date of suspension & reason for the same.

Do you have Dental Treatment Facility

YES