NORTH WESTERN RAILWAY

Application for empanelment of Private hospitals with Jaipur Division Health Units

. Name of the Hospital & Address:

2 Hospital Administration: Private/ Institutional/Corporate/Trusts):

(Attach registration certificate from appropriate authority)

Contaet detail of Hospital3.

4. Telephone/Fax/Email

Empanelment Applied for: (A) Multi-speciality Hospital

(Atach list of specialities)

(B) Single Speciality Hospital(Name of Speciality)

(C) Whether hospital recognised by CGHS/ECHS/ESI:

(Attach Copy of MoU& latest list issued by CGHS/ECHS/ESI through Website)

(D) Whether Accredited (NABH/NABL): (Attach certificate with scope)

(E) Whether already empanelled under Jaipur Division Health Units:

(Attach copy of MoU)

6. Distance Form Railway Hospital/Health Unit:

7. Total No. of Beds

Category-Wise Number of Beds available:

(6) Casualty/Emergency Ward: i) ICCU/ICUNICU

(ii) (iv) (v)

General Semi Private ward Private ward:

2

8. Staff Pattern: (a) Doctors with Qualification

)Full Time Specialist: (Atach list)

(i)Visiting Specialist:(Attach list) ii) RMO with Qualification:

(Attach list)

(b) Nursing Staff Nos. with Qualification:

(Attach list)

(c) Other Para Medical Staff

(Category wise) (Attach separate sheet if necessary)

9. Laboratory facility available (In-house) Status of Laboratory (NABL/Non NABL)

(Attach certificate with scope)

(a) Pathology (b) Microbiology (c) Biochemistry (Attach list of investigation)

Imaging Facility (Status of Lab. NABL/Non NABL):

(a) X-ray (b)

(Yes/ No) (Yes/ No) (Yes/ No)

10.

(Yes/ No) (Yes/ No) (Yes/ No) (Yes/ No) (Yes /No)

Sonography CT Scan (c)

(d) (e)

MRI Portable X-ray Unit

(Attach list of investigation)

Supportive Service

(a) Boilers/ Steriliser

1

(b) Ambulance

(Attach consent letter to provide free ambulance service for railway beneficiaries form & to

railway hospital/Health Units)

(c) Canteen

(d) Waste Disposal System as per prescribed rules

(e) Blood Banks

(f)Pharmacy (In-house) (s) Physiotherapy (h) No. of Operation Theatres

(i) Availability of fire fight system in hospital :Yes/No (Attach NOC)_ G) Authorization from RSPCB Yes/No (Attach document)

(k) Availability of Help desk for Government organisation separately :Yes/ No (Attach consent - Preference must be given to railway beneficiaries)

12. Cardiological Facilities Non Invasive

(a) 2D-ECHO

(b) TMT

(c) Other (Specify)

(Yes/No) (Yes/No)

(d) INVASIVE: (e) Cath Lab :(Yes/No)

(f) Cardiac Surgery OT Yes/No (g) Other (Specify)

13. Haemodialysis/Urology/Uro-surgery/Nephrology/Renal Transplant: (a) Whether the Hospital has in-house Urologist (b) Renal Transplantation Surgeon

(c) Nephrologists (d) Certificate for renal transplant from competent authority :(Yes/No) _

(e) Haemodialysis Unit () Trained Paramedical Staff

:(Yes/No) :(Yes/No) :(Yes/No)

:(Yes/No) :(Yes/No)

14. Trup/Lithotrisy : (Yes/No)

Endoscopic/ Laproscopic Surgery: (a) Endoscopy (6) Laparoscopy Surgery (c) Back Up Open Surgery

15.

:(Yes/No) :(Yes/No) (Yes/No)

16. Orthopaedic: fa) Whether the Hospital has aseptic operation theatre for Orthopaedic procedure :(Yes/No)

(b)Whether lhaving required instrumentation for both Hip and Knee Joint replacement (Yes No)

Facilities for Arthroscopy (c) Facilities for Arthroscopy surgeries

:(Yes/No) : (Yes/No)

: (Yes/No)

(Yes/No) : (Yes/No)

(d) (e) C Arm facility (f) Physiotherapy Unit

(s)X-ray Unit 17. E.N.T.

Essential Information

i. Whether it has required Instrumentation for ENT Surgery and diagnostic procedures

:(Yes /No). Facilities for Nasal Endoscopy :(Yes/No) Facilities for reconstruction Surgery : (Yes /N)

ii. i.

18. Obstetries & Gynaecology (Essential Information) Whether the Hospital has aseptic operation theatre for Gynae&Obst. Procedure

:(Yes/No) (O

Whether having required Gynae & Obst. Instrumentation for both: (Yes /No) 1

i. Facilities for Caesarean Section :(Yes/No) iv. Facilities for Septic & Aseptic Labour: (Yes/No)

19. Paediatric: iNICUPICU :(Yes /No)

:(Yes /No) ii Paediatric Monitor

ii Paediatric Ventilator :(Yes/No) : (Yes /No) iv Hours Back-up of

v Pacdiatric/Neonatologist :(Yes/ No)

20. Neurology / Neuro Surgery: Barrier nursing for isolation patients.

Facility for Gama knife Surgery. ii Facility for Trans sphenoidal endoscopic Surgery. :(Yes /No) iv Facility for Steriotatic Surgery :(Yes /No) v Facility of ITCU

vi Facility of EFG

vii Facility for Electrophysiology study: (Yes /No).

:(Yes/No) :(Yes/No)

i

ii

: (Yes/ No)

:(Yes /No)

21. Gastro-enterology / G. I. Surgery: iRequired instrumentation for G.E./G.I. :(Yes /No) ii Facility for Endoscopy Specify details :(Yes /No)

22. Ophthalmology:

(a) 1OL with phaco-Surgery Facility (b) Well-equipped OT (c) Laser Facility

:(Yes /No) :(Yes /No) :(Yes /No)

23. Cancer Hospital/Services (Infrastructure & Tech. details):-

Onco- Medicine. :(Yes/No) Name of Oncologist with qualifications:

ii Facility of Chemotherapy. iv Onc0- Surgery

v Names of Onco- Surgeon (with qualification):_ vi Whether it has required instrumentation for Oncology Surgery: (Yes/No)_ vii Facilities for Radio Therapy :(Yes/No) vii Names of Radio-Oncologist (with qualification): ix Radio Therapy Facilities & Manpower Shall be as per guidelines of BARC. (Yes/ No) x In house pathology Haematology

: (Yes/No):

:(Yes/No):

:(Yes /No)

24. Diagnostic Centres:

1) Radiology: iRoutine X-Ray ii Sonography

ii Doppler study

: (Yes /No)

: (Yes /No)

:(Yes /No) :(Yes /No : (Yes /No)

:(Yes /No)

iv CT Scan v MRI vi PET Scan

vii Others vii Doctor Qualification

ix Experience x Working Hours

xi Any other facility (Attach separate sheet if necessary)

2) Pathology & Microbiology:

5

iRoutine Haematology : (Yes /No)

ii Histopathology : (Yes /No)

ii Routine biochemistry :(Yes /No)

iv Immuno-assay :(Yes /No)

v Hormone-assay :(Yes /No) vi Routine Microbiology : (Yes /No )

vii PCR :(Yes /No) vii Any other (please specify)

ix Doctors with qualification

x Experience

xi Working Hours

(Attach separate sheet if necessary)

Other Information: Sequence of attached documents should be as under- 25. Submit willingness letter for empanelment with Jaipur Division/Health Units on

institute's letter head addressing to Chief Medical Superintendent, Centra Hospital, Ganpati Nagar, Hasanpura Pulia Jaipur, 302006. Attach prepared checklist.

3. Detail of Registration Shop Act/Corporation/Clinical Establishmentu/Trust Available Specialities in your Hospital& CGHS, ESIC, and ECHS approved specialities on letter head. CGHS,ESIC,ECHS- MoU Copies NABH/NABL Certificate

4.

.

6.

NW Railway MoU Copy if already empanelled with Railway Doctors/staff list

7.

8.

List of Lab Investigations/Imaging Investigations available in your hospital. Free ambulance Consent letter.

9. 10.

Biomedical Waste Agreement. Blood Bank availability.

Pharmacy availability. Fire NOC

11. 12.

13.

14. 15. RSPCB Authorization

Help Desk for railway Patients - Consent on letter head

GSTIN Registration Certificate PAN Number: Attach Copy Bank Account Details:

16. 17. 18.

19.

Income Tax returns for last financial years: List of the organisations/TPAs/ insurance who have empanelled with your hospitals (Sequence- Central Govt., State Govt. TPA etc)

Whether Doctors are available during night time to attend any Emergency or to

undertake operation?Attach hospital prospectus/ Brochure Attach Rate list of CGHS/Jaipur, AlIMS/Delhi, SMS/Jaipur & your hospital rate list with all amendment, corrections etc.

20.

21.

22.

23. 24.

25. Attach all other supportive document relevant of service/ certificates. Attach declaration letter tointimate to railway immediately if any changes status. service, or any change after information provided in application. Attach consent letter to provide regular feedback to railway. Attach consent letter to provide treatment to Railway Beneficiaries on CGHS/Jaipur rates

26.

27 28.

(Copy of document required is to be enclosed.

Other Terms & Conditions strictly treat as per MoU. (Attach consent) 29.

If required separate sheet may be used to give details of the hospitals.

* Conditional offers will not be entertained from the applicant. ** Only applicable columns are to be filled by different applicant.

***Enclose the attested copy of relevant documents.

UNDERTAKING

I hereby certify that all the information furnished above are true to my knowledge. I have

no objection to North Western Railway for verifying any or al the information furnished in this

document with concerned authority, if necessary. T hereby agree to provide cashless treatment service on credit to railway beneficiaries if

empanelled with Jaipur Division Health Units on the rates to be paid by the railway to the hospital as per CGHS rates of Jaipur city, in case the CGHS rate is not available then rates of AlIMS, New

Delhi will be applicable. In case no rate is available in CGHS or AlIMS Delhi then rate offered by hospital with minimum discount or fixed by mutual agreement will be applicable.

Date:

Place:

Signature of the authorized sign Of the Organization

Office Seal

(End of Document|