Government of Haryana • Health Department

Hospital Empanelment Application Form

Chirayu Haryana — State Health Protection Scheme

Fields marked * are mandatory. Upload only PDF files under 2 MB. File names must contain only alphanumeric characters.

Application Type *

Fresh Application Renewal

Hospital Information

Basic details about the hospital

Name of the Hospital *

Address *

State *

District *

Contact Details

Primary contact and nodal officer information

Primary Contact

Designation *

Full Name *

Mobile *

Landline *

Email *

Nodal Officer

Designation *

Full Name *

Mobile *

Landline *

Email *

Accreditation

Hospital accreditation details and certificate

Accreditation Type *

Upload Certificate (PDF) *

Validity Date *

Details of Doctors

Doctors with medical council registration

Name of Doctor	Qualification	Reg. No. (Medical Council)	Validity	Employee Type	Action
					Add More +

Facility & Services

Type of facility, beds and scope of empanelment

Type of Facility *

No. of Beds *

Scope of Empanelment *

Emergency Services *

No. of Beds in Emergency

Pre / Intra / Post Operative Services *

No. of Beds

ICU / CCU Services *

No. of Beds in ICU/CCU

Blood Centre *

Blood Centre Type

Blood Centre License (PDF)

Lab Services *

Details of Lab Doctor(s)

Name	Qualification	MCI/State Council Reg. No.	Action
			Add More +

Out-sourced Lab Documents

Clinical Establishment Act (PDF)

NABL Accreditation (PDF)

Statutory Licenses & Registrations

All applicable licenses and certificates

Registration for PC & PNDT Act *

Status

License for Pharmacy under the Drugs & Cosmetics Acts *

Status

AERB License *

Status

Registration for Mental Health Act *

Status

Registration for MTP Act *

Status

Registration for Narcotics Drugs & Psychotropic Substances Act *

Status

Registration for Transplantation of Human Organs & Tissues Act *

Status

NOC for Fire Safety from Govt. Authority *

Status

Registration for Clinical Establishment Act *

Status

Registration for Ayushman Bharat PMJAY Scheme *

Status

Pre Inspection for Clinical Est. not empanelled under AB:PMJAY

Upload Certificate (PDF)

Infrastructure & Compliance

Waste management, safety and facility compliance

Bio-medical Waste Authorization Certificate *

Upload License (PDF) *

Validity Date *

Consent to Operate under Air and Water Act *

Upload License (PDF) *

Validity Date *

MOU for Bio-medical Waste Management (CBWTF) *

Name of CBWTF *

Validity Date *

Ambulance Service *

Type *

Total No. of Vehicles *

Upload Vehicle Reg. Numbers (PDF) *

Registration of Canteen/Kitchen with FSSAI *

Status *

Central Sterile Supply Department (CSSD) *

Status *

Adequate Parking Area *

Status *

Availability of Oxygen Supply *

Status *

Financial & Legal Documents

TAN/PAN, certificates and undertaking

TAN / PAN *

TAN/PAN Number *

Upload TAN/PAN (PDF) *

Exemption Certificate from Income Tax Office (u/s 17(2)(viii)(B) of IT Act, 1961) *

Upload Certificate (PDF) *

Details of Land Purchased *

Type *

Building Plan Approval / Occupancy Certificate / Rent Lease (Govt. Authority) *

Upload Certificate (PDF) *

Lift Safety Certificate (Haryana Lift & Escalator Act, 2008) *

Upload Certificate (PDF) *

Validity Date *

Undertaking on Letterhead (duly signed & stamped) *

Download Format Download

Upload Signed Undertaking (PDF) *

I hereby declare that the information furnished above is true and correct in every respect. In case any information is found incorrect even partially, the Application shall be liable to be rejected and appropriate action may be taken as per applicable rules.

Ready to Submit? Please review all sections carefully before submitting. This action cannot be undone.