EMPANELMENT FORM FOR HOSPITALS/DAY CARE CENTRES


Healthcare unit should read below mentioned instructions carefully before filling the empanelment form: • Kindly fill the empanelment form in english & block letters. • All the fields marked with “*” needs to be filled mandatorily. • Healthcare unit shall be classified based on the information provided in the form & RHIL reserves the right to physically verify the fact by visiting the centers. • Kindly make sure that all the necessary documents mentioned in the form are attached failing of which application shall be considered incomplete. • All documents need to be duly signed & stamped. • Dispatch of filled form & MOU does not confirm the empanelment of healthcare unit.

Basic Information

Nature of Service Provided (Please tick {√}the appropriate in case of secondary/tertiary service)*


Single Speciality
Multispeciality
Single Speciality
Multispeciality
Contact Information (Please provide correct information about the key contact department)*


Evaluation Parameters(Please provide the appropriate information)*

<15
15-40
40-100
>100

Only OPD
Only IPD
Both OPD & IPD
Casualty/Emergency
24*7 Doctor's Availability
Only Medical
Only Surgical
Medical & Surgical Both
General
Specialized
Labour Room

Sl.No Type Of bed* Bed/Room Name(As per hospital)* Total Count*
A AC Suite
B AC Single
C Non AC Single
D AC Twin Sharing
E Non AC Twin Sharing
F Multi-Sharing (3-4 Beds)
G General Ward (AC/ Non AC)
H ICU/ ICCU / MICU/ SICU/ NICU
I Other (Any specific type other than mentioned above)
Autoclaving
lonizing/Non-lonizing (UV) Radiations
Antiseptics
Disinfectants
Fumigation
All of the Above
Sl.No Type Of Service OPD IPD Monitoring Therapeutics
A Primary Care Service
B General Medicine/Internal Medicine
C Pediatrics (Child-Care)
D Orthopedic (Bones & Joint)
E Ophthalmology (Eye)
F Ear, Nose & Throat (ENT)
G Gynecology & Obstetrics
H Cardiac (Heart)
I Neurology (Nervous System)
J Urology (Urinary Tract)
K Oncology (Cancer)
L Nephrology
M General medicine/Internal medicine
N Gastroenterology
O Other(Specialties if any)
Infrastructure and Other Details
Allopath
Ayurvedic
Homeopath
Trust
Mission
Private
Govt
NABH
ISO
JCI
NABL
Within Premises
Outside Premises
Not Available
Paid parking
Motor to Premises
Premise to Lift
By Trolly to Bed

Sl.No Facility 24 hrs 12 hrs 6 hrs Less Than 4 hrs
A Water Supply
B Electricity
C Generator Back-up
D UPS for Critical Areas
E UPS for All Areas
24 hrs Waiting Room
24 hrs Computerized Billing
Canteen for Patient Relatives
Patient Food Included in Accommodation
STD/FAX/Xerox Available
Direct Phone Access to Ward & ICU
Elevator Big Enough to Accommodate Trolley

Sl.No Facility Strength Classification Yes/No Comments (if any)
A In-House Pharmacy Yes No
B Laboratory Hematology Yes No
Biochemistry Yes No
Microbiology Yes No
Pathology Yes No
Serology Yes No
Histopathology Yes No
Endocrine Lab Yes No
C Radiology/Imaging X-Ray Yes No
Portable X-Ray Yes No
Ultra Sound Yes No
Colour Doppler Yes No
CT Scan Yes No
MRI Yes No
D Ambulance General Yes No
Cardiac Yes No
Neonatal Yes No
Ventilator Support Yes No
Doctor Accompanying Yes No
E Cath lab Yes No
F Blood Bank Yes No
G Mortuary Yes No
H Dialysis Unit Yes No
I Emergency/Maintenance Services Casualty Yes No
RTA Cases Yes No
Cardiac Emergency Yes No
J Medical Record Management Yes No
K Laundry/Security/Housekeeping Yes No
L Full Time Doctors/RMO’s/Nursing staff Yes No
i) Hydraulic
ii) Manual
b) Suction
c) Electrocautery
d) C-Arm/Boyle’s Apparatus
e) Cardic Monitor
f) Cardiac Defibrillator
Enclosures (Mandatorily to be submitted by the hospital)*
Hospital Registration Certificate* PAN Card Copy (In case payee name differs, attach both PAN Copies)*
Tariff Card/Rate-List* List of Consultants (OPD Schedule)*
Cancelled Cheque (Original only)* NIL/Lower TDS Certificate (If Any)
Service Tax Registration Copy (If Any) Doctor’s Registration Copy (If owned by a Medico)
List of Nursing/Paramedical Staff Biomedical Waste Management Certificate
NEFT Declaration Form* Bank Statement Pass Book Copy*
NABH Registration Certificate* Copy of Fire & Safety Department Clearance Certificate*
Information filled by(To be filled by the hospital)*

I/we hereby declare that the information furnished in the given form is correct to the best of my/our knowledge & belief. I/we fully understand that RHIL officials may verify the information on this form & if any information furnished above, proved incorrect or false will render me/us liable for any penal action or other consequences as may be prescribed in law or otherwise warranted.

Corporate and Registered Office: Reliance Health Insurance Limited, Reliance Centre, 1st Floor North Wing, Santacruz (East) Mumbai - 400055. Customer Care Number: 022 - 33426868 | Email: reliancehealth.service@relianceada.com | Website : www.reliancehealthinsurance.com