Application Form For Empanelment Under Ayush Medical Reimbursement Policy
Name of the hospital
*
Address
*
State
*
Select
Andaman and Nicobar Island (UT)
Andhra Pradesh
Arunachal Pradesh
Assam
Bihar
Chandigarh (UT)
Chhattisgarh
Dadra and Nagar Haveli (UT)
Daman and Diu (UT)
Delhi (NCT)
Goa
Gujarat
Haryana
Himachal Pradesh
Jammu and Kashmir
Jharkhand
Karnataka
Kerala
Lakshadweep (UT)
Madhya Pradesh
Maharashtra
Manipur
Meghalaya
Mizoram
Nagaland
Odisha
Puducherry (UT)
Punjab
Rajastha
Sikkim
Tamil Nadu
Telangana
Tripura
Uttarakhand
Uttar Pradesh
West Bengal
District
*
Select
Contact Details
*
Select
Medical Superintendent
Medical Director
Senior Officer
Accreditation
*
Select
NABH
Entry Level NABH
Upload accreditation certificate
*
Accreditation Valid From
Validity (date)
*
Speciality Type
Empanelment Period From
Empanelment Period Till
Enpanel Status
Details of doctors, along with their registration with relevant councils
*
Name of Doctor
Qualification
Registration Applicability
Registration No
Validity
Employee type
Add/Remove
Select
Yes
No
Select
Regular
Contractual
Part-time
On-call
Etc
Add More +
Type of facility / Hospital
*
Select
Ayurveda
Homeopathy
Unani
Sidha
Yoga
Naturopathy
No. of Beds
*
Lab Service
*
Select
In House
Out Source
NOC for Fire Safety from Govt. Authority
*
Select
Yes
No
Upload certificate
Building Plan approval/Occuancy Certificate/Permission from compitent Govt Authority (Upload certificate)
*
Registration for Clinical establishment Act
*
Select
Yes
No
Upload certificate
X-Ray Services
*
Select
Applicable
Not Applicable
Upload certificate issued by AERB
TAN/ PAN
*
TAN/PAN No.
Upload TAN/PAN
GST NO.
*
Applicability
Select
Yes
NO
Upload Documents
Bio-medical Waste Management
Availablity
Select
Yes
NO
Name of CBWTF
Validity (date)
Kitchen / Canteen
*
Availablity
Select
Yes
No
FSSAI certificate/any other Certificate for registration
Pharmacy / Medical Store
*
Select
In House
Out Source
Ambulance Service
*
Select
In House
Out Source
Upload MOU (in case of Outsource)
Name and Address of Banker *
Bank Name
*
Account No.
*
IFSC Code
*
Branch Address
*
Availablity of Lift
*
Availablity
Select
Yes
No
Registration Certificate
Non refundable application fees of Rs 5000/- *
Demand Draft No.
*
Upload Demand Draft
*
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
*