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Network Hospital Grading Proforma: General Information
Network Hospital Grading Proforma: General Information
Ltd
No.1, New Tank Road, Valluvarkottam High Road,
Nungambakkam, Chennai – 34. www.starhealth.in
Toll free No: 1800 425 2255 BOARD No: 044 - 28263300
Address
Total Land Area ____________________ , Super Built up Area __________________(Area in Sq. Feet)
Hospital Type: Multi Specialty Single Specialty Clinic Other (specify
(Please tick the appropriate box)
If single specialty please mention the specialty:_____________ Number of Total Beds in the Hospital:
Contact Details:
Contact Person for Name Tel. No. Ext. Mobile No.
Head of Operation/ admin
Accounts and Billing
Admission
Clinical Information
Interaction with Star
Medical Records
ICU
Casualty
Operation Theater/Labour Room
1 Date:
Form Confidential Signature & Seal
STAR HEALTH AND ALLIED INSURANCE CO. Ltd
No.1, New Tank Road, Valluvarkottam High Road,
Nungambakkam, Chennai – 34. www.starhealth.in
Toll free No: 1800 425 2255 BOARD No: 044 - 28263300
OT – COMPLEX:
Vinyl Floor
Type of OT Table/Ortho
attachment
Capnography
C-Arm – Specification
Radiant Warmer
Autoclave
Others
2 Date:
Form Confidential Signature & Seal
STAR HEALTH AND ALLIED INSURANCE CO. Ltd
No.1, New Tank Road, Valluvarkottam High Road,
Nungambakkam, Chennai – 34. www.starhealth.in
Toll free No: 1800 425 2255 BOARD No: 044 - 28263300
ICU \ IMCU :
Monitor
Pulse Oxymeter
Others
Details of Beds
Burns Unit
3 Date:
Form Confidential Signature & Seal
STAR HEALTH AND ALLIED INSURANCE CO. Ltd
No.1, New Tank Road, Valluvarkottam High Road,
Nungambakkam, Chennai – 34. www.starhealth.in
Toll free No: 1800 425 2255 BOARD No: 044 - 28263300
Diagnostic Services
Lab Services Yes No Description
Hematology
Biochemistry
Microbiology
Serology
Histopathology
Biomedical Department
Digital X-Ray
Contrast Studies
Portable X-ray
Ultra Sound
Mammogram
CT- Scan
MRI
PET Scan
4 Date:
Form Confidential Signature & Seal
STAR HEALTH AND ALLIED INSURANCE CO. Ltd
No.1, New Tank Road, Valluvarkottam High Road,
Nungambakkam, Chennai – 34. www.starhealth.in
Toll free No: 1800 425 2255 BOARD No: 044 - 28263300
Multi specialty Hospital - please indicate the specialties available in your hospital: (Please tick the appropriate box)
ECG
ECHO
TMT
Holter Monitor
Cath Lab
Nuclear Scan
Audiometer
Triple Endoscopy
OGD
Colonoscopy
ERCP
Labour Room
Fetal Incubator
Neonatal resuscitation kit
Fetal Monitor
Neonatal ICU
5 Date:
Form Confidential Signature & Seal
STAR HEALTH AND ALLIED INSURANCE CO. Ltd
No.1, New Tank Road, Valluvarkottam High Road,
Nungambakkam, Chennai – 34. www.starhealth.in
Toll free No: 1800 425 2255 BOARD No: 044 - 28263300
Phaco
Laser
6 Date:
Form Confidential Signature & Seal