APPLICATION FORM FOR RECOGNITION  OF  PRIVATE HOSPITALS, NURSING HOMES CLINICS &  PATHOLOGICAL LABORATORIES  FOR TREATMENT OF  STATE GOVT. EMPLOYEES

 

 To:-

 

The Chief Medical & Health Officer

District....................................(M.P.)

 

Subject:- Application  for recognition  of  private hospitals, nursing homes clinics &  pathological laboratory for treatment of  state govt. employees .

 

Dear sir,

 

I  am submitting my application for recognition  of  my private hospital/, nursing home/ clinic/  pathological

laboratory  for treatment of  state govt. employees. The particulars of  my institution  are given below.

 

Name of Hospital/ Lab/Nursing Home/clinic ...................................................................

Registration No .......................................................................................................

Address House No. ........... ward....................Mohalla......................Lane......................

Area..................... City................... Pin code................District......................M.P.

 

( Please attach an approach map of  the  site )

 

Name of owner/Director.............................................Qualification................................

Telephone No................................................................ E- mail No............................

Year & Month  of  establishment ..................................................................................

Registration  details of institution under any other act ( PNDT, MTP, Sterilization scheme etc.)  .....................................................................................................................

Was the institution ever recognised by state/ central Govt...............................................

Whether Income tax return is  filed ? IT   No..................................................................

Audit certificates of last two years may be attached.......................................................

Details  of the  Investigations / Procedures/ Services applied for recognition........................

 .............................................................................................................................

Rate  list/ Charges for investigations & Services with justification.......................................

  .............................................................................................................................

Yearly report of Investigations / Procedures/ Services applied for recognition........................

 ..............................................................................................................................

Manpower position of the  facility ( Names with qualifications & skills,  attach separate sheet

mentioning No. of trained & untrained staff/ Doctors/ Specialists........................................

Infrastructure details about  building ( Attach Map).........................................................

Number of rooms, laboratories, Wards, Examination rooms, OPD rooms, Sp. Investigation rooms.

(Attach  a map showing all facilities) ............................................................................

 ..............................................................................................................................

Availability of  floor space as per norm ...........................................................................

What is the system of record keeping for patients. Is the stock register , Patient  register indoor

 & out door investigation register  maintained ? ( average patient related statistics may be shown)....................................................................................................................

Are facility for emergency services available? ( Give  details of Emergency equipments, drugs

oxygen & resuscitation facilities) .................................................................................. ..............................................................................................................................

List of equipments  available for the investigations/ examination, their  make etc.

 .............................................................................................................................

Arrangements available for pathological & biochemical & Bacteriological investigations  ..........  ...............................................................................................

Details of operation theatre,  space, No. of rooms, autoclaving arrangements,

Details of equipments, anesthesia used, and  instruments availability, emergency light

(this is required in case an operative procedure is requested for recognition)....................... .............................................................................................................................

Facilities available  for  dealing  with emergency .............................................................

Any other information about your institution you want to give...........................................

 

 

 

Date......................................                                                                 Signatures

Name...........................................

Place .....................................

 

 

DECLERATION FORM

I  ...................................... do hereby declare  that the information given  by me in the  form is fully correct to the best of my knowledge & belief . I know that if any of the  information is  found fictious or incorrect the recognition of the institution  will be cancelled . I also solemnly declare  that I will charge the  amount  fixed by the Govt. for the Govt. employees. In case any amount higher than the  Govt. approved rate is charged will be considered as the breach in the contract. I also declare that  institution shall follow the rules & regulations under which the recognition is granted to the institution.

 

 

 

Date......................................                                                                 Signatures

Name.....................................

Place ....................................