EmpanelMent

Application Form

Name of the hospital *

Address *

State *

District *

Contact Details *

Accreditation *

Upload accreditation certificate *

Validity (date) *

Details of doctors, along with their registration with relevant councils *

Name of Doctor	Qualification	Registration No. with medical Council	Validity	Employee type	Add/Remove
					Add More +

Type of facility *

No. of Beds *

Scope of empanelment *

Emergency Services *

Pre /Intra/ Post Operative Services *

ICU / CCU Services *

Blood Centre *

Lab Services *

Name	Qualification	MCI/State council registration
			Add More +

Registration for PC & PNDT Act *

License for Pharmacy under the Drugs & Cosmetics Acts *

AERB License *

Registration for Mental Health Act *

Registration for MTP Act *

Registration for Narcotics Drugs & Psychotropic Substances Act *

Registration for Transplantation of Human Organs & Tissues Act *

Type of organ	Validity (date)	Upload License

Bio-medical Waste Authorization Certificate *

Upload License *

Validity (date) *

Consent to Operate under Air and Water Act *

Upload License *

Validity (date) *

MOU for Bio-medical Waste Management *

Name of CBWTF *

Validity (date) *

NOC for Fire Safety from Govt. Authority *

Registration for Clinical Establishment Act *

Registration for Ayushman Bharat PMJAY Scheme *

TAN/ PAN *

TAN/PAN No.

Upload TAN/PAN

Exemption certificate from Income Tax Office under sub-clause (B) of clause (II) of the proviso to sub-clause (VIII) of clause (2) of section 17 of the Income Tax Act, 1961. *

Upload certificate *

Details of the land purchased *

Building plan approval/ Occupancy Certificate/ Rent Lease, issued by Govt. Authority. *

Upload Certificate *

Lift safety Certificate for each of the lifts installed in the hospital premises, issued by Govt. Authority under the Haryana Lift & Escalator Act, 2008 or any other relevant instructions for hospitals situated outside Haryana. *

Upload Certificate *

Validity (date) *

Ambulance Service. *

Select

Total number of Vehicles *

Upload registration numbers of all vehicles *

Registration of canteen/kitchen with FSSAI, if available in the premises of hospital. *

Select

Central Sterile Supply Department (CSSD.) *

Select

Adequate Parking Area. *

Select

Availablity of Oxygen Supply *

Select

Kindly submit undertaking (as per format) on letterhead, duly signed & stamped *

Download
Format

Upload Undertaking *

I hereby declare that information furnished above is true and correct in every respect and in case any information is found incorrect even partially the Application shall be liable to be rejected *