Page 1 of 22

Application Form (For Secondary Medical Care, Diagnostic Services)

(For empanelment of Hospitals/Diagnostic Centers/ Imaging Centers for Secondary treatment,
investigation)
To,
The Regional Director,
ESIC, Regional Office (Bihar)
Panchdeep Bhawan, Income Tax Golamber,
J.L. Nehru Marg Patna 800001

Subject: - Expression of Interest (EoI) for Empanelment of Hospital,

Diagnostic Centers.

Sir,
With reference to your Notice Inviting EoI Published in the newspaper / website
dated ……………… I/ We wish to offer the following services for ESI beneficiaries on
cashless basis.
1.
2.
3.
4.

The Parties having more than one service and fulfilling the eligibility requirement may
choose for one or more categories.

I/ We agree to abide by the terms and conditions of the EoI document and I/ We also certify
that the information as submitted by me/us in Annexure I, II, III, IV and V is correct and
I/ We fully understand the consequences of default on our part, if any.

Place: (Name and signature of the

Proprietor)

Date:
 Page 2 of 22

Check List-
S SN
Check Points Yes/ No Check Points Yes/ No
N
Bank Account Details (Self
1 Application Form l
Attested Photo Copy)
Experience in Full Year
2 Check List Filled m
supported by Certificate
Eo I Form duly Signed & Audited Balance Sheet & P
3 n
Stamped on all pages) & L Account for last 1 Year
Annexure V
4 Annexure I o

5 Annexure II 7 Legal Status (Self Attested

Photo Copy)
Place of Registration ((Self
6 Annexure III a Attested Photo Copy)
Self Attested Photo copy of Place of Business
a b
NABH Accreditation
Self Attested Photo copy of Partnership Deed/ AOA/
b c
NABL Accreditation MOA (Self Attested Photo
Copy)
Rate List of Hosp. in Hard Specialty Approved by
c Copy (Duly signed & d CGHS (Self Attested Photo
Stamped) Copy)
Self Attested Photo copy of Full Time Specialist on Roll
d Registration Certificate of 8 (List of Specialty with their
Hosp. Certificates)
Self Attested Photo copy of Full Time Technicians (List
e Registration & Qualification 9 of Technicians with their
Cfts. of Specialist Certificates)
Self Attested Photo copy of Requisite Fee
f Registration & Qualification 10
Cfts. of Technicians etc
Self Attested Photo copy of
g Bio Medical Waste 11 Self Attested Photo copy of
Management Certificate ESI Coverage Letter
Self Attested Photo copy of Self Attested Photo copy of
h 12
Fire Clearance Certificate EPF Coverage Letter
AERB Approval for Documents arranged as
i 13
Radiology Certificate per the sequence of this
Check List
Under Taking as per
j
Annexure IV
PAN Card (Self Attested
k
Photo Copy)
 Page 3 of 22

Annexure-I

TERMS AND CONDITIONS

(Please read all terms and conditions carefully before filling the application form and
Annexure thereto)

I. General Terms and Conditions:

a) Hospital applying for EoI should submit application forms along with the prescribed fee,
annexures and documents prescribed herein.
Duly completed EoI forms may either be dropped in person in the box earmarked for the
purpose kept at the Regional Office or be sent by Registered/Speed post. The sealed envelope
should be super scribed “EoI for empanelment of Hospitals/ Diagnostic Centre/Imaging
Centre”

Documents received after the scheduled date and time (either by hand or by post) or
unsealed EoI or EoI received through e-mail/fax or without the prescribed fee shall not be
processed and will be rejected.
b) EoI Cost of document Rs. 1000/- (Non-refundable) should be paid through online payment
in bank Account “ESIC RO-2” (SBI Account No. 11049770948 IFSC Code SBIN0000152)
c) Rates of package and procedure/investigation will be as per CGHS (Patna) rates as revised
from time to time or Hospital rate whichever is less. Where CGHS (Patna) rates are not
available CGHS rates of nearby cities as per CGHS guidelines, AIIMS/ Government
Hospital Rates, if available, will be applicable.
d) One or more hospitals may be empanelled in a particular area depending upon the
requirements.
e) Application form and (Annexure I, II and/ or III, IV& V) should be duly filled and
signed by the proprietor or Director or duly authorized person with official
seal/rubberstamp.
f) An Agreement on Non Judicial stamp paper of appropriate value shall be signed by
Hospitals/ Diagnostic Centers/Imaging Centre that are approved for empanelment after
scrutiny of EoI and evaluation thereof. The incidental charges related to agreement shall be
borne by the Empanelled Centre.

Only those applications will be considered for issue of proposal for

empanelment that fulfill all the eligibility conditions and also have satisfactory report
of inspection committee as may be constituted by REGIONAL DIRECTOR. EoI must
be accompanied with all prescribed mandatory documents duly verified and signed,
failing which the EoI will not be entertained.

g) Period of Empanelment:

The empanelment shall be initially for a period of two years which may be extended for
another one year or for further period on year to year term basis on satisfactory performance
and mutual consent.
 Page 4 of 22
II. CONDITIONS FOR EMPANELMENT

1. The Health Care Organizations (HCOs) which are empanelled by CGHS/state Govt. need to
submit a consent letter accepting the terms and condition mentioned here in along with the EOI
document duly signed and stamped and also specify the specialty treatment and investigations
approved by the CGHS/ State Govt./ Public sector.
2. For all other Health Care Organization (Other than those empanelled with CGHS/State
Govt.) following criteria need to be fulfilled:
i. The Health Care Organizations should preferably be accredited by National Accreditation
Board for Hospitals & Healthcare Providers(NABH)
ii. The diagnostic laboratories should have been accredited by National Accreditation Board
for Testing and Calibration Laboratories(NABL).
iii. ESIC also reserves the right to prescribe/revise rates for new or existing treatment
procedure(S)/investigation(s) as and when CGHS revises the rates, or otherwise.
iv. The health care organization must have the capacity to submit all claims – bills in electronic
format to the ESIC / ESIS system and must also have dedicated computer equipment,
software and connectivity for such electronic submission in UTI-ITSL portal.
v. The health organization must give an undertaking appended at Annexure- IV that they shall
charge as per CGHS rates and that the rates charged by them are not higher than the rates
being charged by them from other patients who are not ESI beneficiaries.
vi. Hospital must adopt CGHS rates for unlisted treatments and should not hike the bills
intentionally by ignoring CGHS approved rates for “OTHER MAJOR SURGERY/OTHER
MINOR SURGERY’ applicable to all treatment procedure not mentioned in CGHS list.
vii. The health care organization must certify that they are full filling all special conditions that
have been imposed by any authority in lieu of special concessions such as but not limited to
concessional allotment of land or custom duty exemption, etc. The health care organizations
(Except exclusive eye hospitals / centers, exclusive dental clinics / Diagnostic laboratories/
imaging Centre) must agree for implementation of EMR/EHR as per the standards notified
by ministry of health and family welfare within one year of their empanelment.
viii. The HCO must mention the specialities which have been approved by CGHS/State
Govt. /Public Sector/Insurance Companies in their consent letter.
ix. Hospital will have to nominate one official as ESI Nodal Officer who will work as
Single Point of Contact (SPOC) to facilitate ESI beneficiaries.
x. The health care organization shall have minimum experience of 1 (one) year in the
specialties/services applied for.
xi. The health care organization must possess basic infrastructure (Equipment related or
Qualified Human Resource related) to provide the treatment/services applied for. The health
care organization shall also have ICU facilities/life-saving facilities in case of emergency.
The health care organization shall also have in-house lab/investigation infrastructure
required for the services applied for.
xii. The health care organization shall have full time concerned specialist/technical/skilled
manpower on their roll so that the treatment/services can be provided smoothly.
xiii. The health care organization shall have valid PAN, Bank Account.
xiv. The health care organization should be in operation for at least one full financial year.
xv. The Annual turn over of the Health Care organization should be more than Rs. 25 Lakh.
xvi. The hospital should have minimum 30 bed facility for indoor treatment. Eye Clinic/
Dental Clinic/ Diagnostics Center/ Imaging Center are exempted from this minimum bed
criteria.
 Page 5 of 22
III. COPIES OF DOCUMENTS REQUIRED FOR EMPANELMENT.

a) Copies of all the documents mentioned in the Condition for empanelment in

Annexure-V.
b) Copy of NABH/ NABL application in case of Non-NABH/Non -NABL accredited Health
Care Organization.
c) Copy of NABH/ NABL Accreditation in case of NABH/NABL accredited Health Care
Organizations. (if accredited)
d) List of treatment procedure/investigation/facilities available in the Health Care Hospital
Rate list of available procedure, treatment Organization.
e) State registration certificate/ Registration with Local bodies, wherever applicable.
f) Compliance with all statutory requirements including that of Bio-medical Waste
Management.
g) Fire Clearance Certificate/ Certificate by authorized third party regarding the details of Fire
safety mechanism as in place in the Health Care Organization.
h) Registration under PNDT Act, for empanelment of Ultra sonography facility, wherever
applicable.
i) AERB approval for tie-up for radiological investigations/Radiotherapy, wherever
applicable.
j) Certificate of Undertaking as per the Annexure-IV
k) Photocopy of PAN card.
l) Bank details along with copy of passbook.
m) The Health Care Organization must have been in operation for at least one full financial
year. Copy of audited balance sheet, profit and loss account for the preceding financial year
to be submitted (Main documents only)
n) The empanelled centre will have to report on daily basis the details of admitted patient for
indoor treatment to Regional Director, Bihar on e-mail address rd-bihar@[Link] in the
prescribed format.
o) Private Hospitals / clinics should be registered under ESI Act, 1948/Social Security code-
2020 (if employing 10 or more employees) and EPF & MP Act as per the provisions of
those Act.

IV. Duties and Responsibility of Empanelled Hospitals/Diagnostic Centres

1. It shall be the duty and responsibility of the hospital / Diagnostic centre at all times, to
obtain, maintain and sustain the valid registration and high quality & standards of its
services and healthcare and to have all statutory/mandatory licenses, permits or approvals of
the concerned authorities as per the existing laws.
2. Display board regarding cashless facility for ESI beneficiary should be displayed at
prominent location/places of the hospital.
3. The list of necessary documents required to be carried by ESI patient/attendant for
treatment/investigation at the Empanelled Hospital/ Diagnostic Centre must be displayed on
the board. A help desk shall be there for facilitation of ESI beneficiaries. Official of
Hospital will be nominated as ESI Nodal Officer to work as SPOC for ESI beneficiaries.

4. The hospital will have to follow the direction/Instruction of ESIC regarding procedure of
referral and presenting of bills.
5. UTI-ITSL is appointed by ESIC for bill processing. The hospital should be ready to present
bill as per procedure adopted online (UTI-ITSL Standard operating procedure SOP
enclosed) as required by billing agency UTI- ITSL.
6. The Hospital/ Dialogistic Centre/ Imaging Centre selected for empanelment shall have to
register them in billing agency esicbpa UTI-ITSL Portal for starting working with ESIC.
They have to comply with all the terms and conditions laid down in SOP and any further
 Page 6 of 22
changes therein accepted by ESIC.
7. The Hospital/ Dialogistic Centre/ Imaging Centre selected for empanelment shall have to
obtain Digital Signature at their own cost to enable to upload any documents in UTI-ITSL
billing portal.

V. Mandatory Instruction for Tie-up Hospital & Diagnostic Centers-

1) Referral Hospital is instructed to perform only the procedure / treatment for which the
patient has been referred.
2) Procedure of referral general and emergency case to be followed as per ESIC Operational
manual 2015 for SST and other guidelines issued by HQ from time to time. In case of
‘‘Road Traffic Accident, work place accident or in case of life threatening emergency,
ESI beneficiary shall be directly admitted, given treatment and intimation to be
generated online in UTI-ITSL portal for verification and approval of referral.”
3) In case of additional procedure / treatment / investigation is essentially required in order to
treat the patient for which he /she has been referred to, the permission for the same is must
be taken from the referring authority/ Doctor as per UTI-ITSL SOP.
4) The hospital may need to provide OPD consultation at CGHS rates to ESI beneficiaries, as
per guidelines issued from ESIC and raise online bill of OPD consultation in UTI-ITSL
billing system accordingly.
5) Once the ESI beneficiaries attends the tie-up hospital, the prima facie verification regarding
identity of beneficiaries in terms of genuineness shall be ascertained by the hospital from
UTI-ITSL application/ ESIC portal.
6) The referred hospital has to raise the bill as per the agreement on the standard Performa of
ESIC along with supporting documents within 15 days of discharge of the patient giving
account number and RTGS number etc. as per form P-II
7) The tie-up hospitals shall raise the bills on their hospital letter head with address and e-
mail/fax number of the hospital, as per the P-II and P-III format which will be provided at
the time of agreement. The tie-up hospitals shall raise the bills with supporting documents
as listed in P-III duly signed by the authorized signatory. The specimen signatures of the
authorized signatory duly certified by competent authority of the tie-up hospital shall be
submitted to all the referring ESI system. The bills which are not signed by the authorized
signatory and are incomplete or not as per the format will not be processed and shall be
rejected. Any change in the authorized signatory shall be promptly intimated by the tie-up
hospital to all the referring ESI system and REGIONALDIRECTOR.
8) The drugs prescribed at the time of discharge of the patient after treatment shall be issued
by tie-up hospital for seven days for which the tie-up hospital can claim Rs. 2000/- or
actual cost per patient, whichever is less, in the claimed bill. Afterwards all the medicines
shall be issued by the ESIS system.
9) Food supplement will not be reimbursed.
10) All the drugs / dressing used during the treatment of the patient requiring reimbursement
should be of generic nature.

11) Only those medicines to be used which are FDA/ID/BP or USP pharmacopeia approved /
DG ESIC rate contract. Any drug / dressing will not covered under any of these
pharmacopeia will not be reimbursed.
12) The tie-up hospital will not charge any money from the patient/ attendant referred by
ESI system for any treatment / procedure / investigation carried out. If it is reported
that the tie up hospital has charged money from the patient then action may be taken
against the concerned tie-up hospital for de- empanelment/ black listing. In case if any
complain is received with reference to the charging of money by the tie-up hospital, the
concerned bill of the complainant IP will not be passed and double the amount of
alleged charged money will be withheld from pending bills of the tie-up hospital.
13) The Tie-up Hospital shall not ask the patient or his/her attendant to provide separately the
 Page 7 of 22
medicine/sundries/equipments or accessories from outside as cost of all these items is
included in the CGHS package rate.
14) Cashless treatment shall be provided to only those ESI beneficiaries who have been referred
to ‘Tie-up’ hospitals following the referral procedure of ESIC/ESIS referral system, or post
facto referral.
15) For any interpretation of procedure or package or treatment or any things related to the
patient the guideline laid under CGHS rules will be applicable.

16) In case of life threatening emergency / road accident cases or accident at work place
(including to/ from work place i.e. employment injury cases), the empanelled hospital shall
provide the treatment of the ESI beneficiaries on cashless basis even without referral.
However the empanelled hospital shall immediately seek ex-post facto referral approval
from ESIC by generating online intimation in UTI-ITSL Portal within 48 hours from
admittance of the ESI beneficiaries in Tie-up Hospital.
17) Before starting treatment/consultation/investigations of the ESI beneficiaries in respect of
the empanelled hospitals/diagnostic centre will have responsibility to check the
eligibility/entitlement of the Insured Persons (IPs) online from ESI portal ([Link]) on
their own also. In case of doubt clarification may be sought from ESIC, BO or REGIONAL
DIRECTOR Office.
18) In case of any natural disaster/epidemic, the hospital/diagnostic centre shall have to fully
cooperate with ESIC and will convey/reveal all the required information, apart from
providing treatment/investigation facility.
19) Before starting the treatment the Empanelled Hospital or centre should ensure that
following documents duly signed by referring authority are attached with the referral letter-
a) Duly filled and signed referral per forma.
b) Attested copy of Insurance card/photo I-card of IP/ e-pehchan Card.
c) Referral recommendation of specialist or concern medical officer.
d) Attested copy of entitlement certificate.
e) Reports of investigation and treatment already done.
f) One additional latest photograph of the patient.

20) The details of documents to be submitted along with the bill are as follows:-
a) Discharge slip duly verified by treating doctor incorporating history of the case, diagnosis,
details of procedure done/treatment given and medicine given/advised on discharges along
with the duration of hospital stay. Discharge slip should be accompanied with the copy of
the case sheet. The discharge slip should have signature of the beneficiary/attendant and
treating consultant in original also with his/her stamp.
b) Reports of investigations in original duly verified.
c) Original bills of implants/devices etc duly verified by the treating consultant should be
attached. The bill should have detail of the implant/device i.e. batch no. size, quantity,
expiry date.
d) Stickers of implants duly verified by the treating consultant should be attached.
e) Referral Slip (P-1)/OPD slip by ESIS dispensary/secondary care ESI hospital/ IMP/ DCBO/
SMO.
f) Medicine bill duly verified by treating doctor and chemist/store In-charge. A certificate
stating that it is certified that the drugs used in the treatment are in the standard
pharmacopeia- IP/BP/USP/FDA (tick whichever is applicable).
g) P-III, P-V, P-VI, as may be applicable form duly filled and signed as required therein.

21) High cost treatment.

a) The ESI will bear the full cost of treatment, wherever CGHS package rates are available
up to the limit of package rate.
 Page 8 of 22
b) Upper limit on the expenditure for procedure not covered under CGHS package rates
would be Rs.10 lac per beneficiary per year.
c) Such cases of non-package treatment involving expenditure of more than Rs.10 lac may
be reported to Regional Director well in advance for seeking ESIC Headquarters
approval. Considered only as and exception and on reimbursement basis. The
reimbursement proposal of such cases shall be submitted to Hqrs. Office for
consideration and approval by ESI Corporation, on case to case basis.

d) In case of malignancy and chronic renal failure, pre-existing disease will not be eligible
for coverage.
e) In respect of organ transplant and bone marrow transplant, the payment shall be
restricted only to the rates applicable for related donor. This will reduce potential
misuse. Further, in respect of organ transplant involving the malignancy, the organ
transplant is restricted to transplant of the organ having primary malignancy.
f) Treatment in case of malignancy at tie up hospitals shall be eligible only for
surgery/chemotherapy/Radiotherapy. Any additional treatment/procedure shall require
specific recommendation by Medical Board, duly constituted for the purpose at the ESI
Hospital concerned.
g) The cost of artificial limbs is to be restricted to a ceiling of Rs.1.00lac.

22). Empanelled Hospital/Centre shall comply with all directions in connection with medical
services for ESI beneficiaries issued from time to time by REGIONAL DIRECTOR.

VI. Non Assignment

The empanelled Hospital, Diagnostic Laboratory/ Imaging Centre shall not assign, in whole or in
part, its obligations to perform under the agreement, except with the ESIC’s prior written consent at
its sole discretions and on such terms and conditions as deemed fit by the ESIC. Any such
assignment shall not relieve the Hospital/Eye centre/Dental clinic/Diagnostic Centre from any
liability or obligation under this agreement.

VII. Empanelled Health Care Organization’s Integrity and Obligations during Agreement
Period
The empanelled Hospital, Diagnostic Laboratory/Imaging Centre is responsible for and obliged to
conduct all contracted activities in accordance with the Agreement using state-of-the-art methods
and economic principles and exercising all means available to achieve the performance specified in
the Agreement. The Hospital, Exclusive Eye centre, Exclusive Dental clinic, Diagnostic
Laboratory/Imaging Centre is obliged to act within its own authority and abide by the directives
issued by the ESIC. The Hospital, Exclusive Eye centre, Exclusive Dental clinic, Diagnostic
Laboratory/Imaging centre is responsible for managing the activities of its personnel and will hold
itself responsible for their misdemeanors, negligence, misconduct or deficiency in services, if any.

VIII. Performance Bank Guarantee (PBG)

Health Care Organizations that are recommended for empanelment after the initial assessment shall
also have to furnish a performance Bank Guarantee valid for a period of 30 months i.e. six month
beyond empanelment period to ensure efficient service and to safeguard against any default:
Hospitals/Cancer Units Rs. 5.00 lac
Eye Centres Rs. 2.00 lac
Dental Clinics Rs. 2.00 lac
Diagnostic Centres Rs. 2.00 lac
(PBG for charitable Organizations would be 50% of above amount)
 Page 9 of 22
In case of health care organizations already empanelled under ESIC they shall submit a new
Performance Bank Guarantee after the validity of the existing performance guarantee is over.

Forfeiture of Performance Bank Guarantee and Removal from List of Empanelled

Organizations
In case of any violation of the provisions of the MOA by the health care organizations empanelled
under ESIC such as:
1. refusal of service,
2. undertaking unnecessary procedures,
3. prescribing unnecessary drugs/test,
4. over billing,
5. reduction in staff/infrastructure/equipment etc. after the hospital/has been empanelled,
6. Non-submission of the report, habitual late submission or submission of incorrect data in the
report.
7. Refusal of credit to eligible beneficiaries and direct charging from them,
8. If not recommended by NABH/NABL/QCI at any stage,
9. Discrimination against ESIC beneficiaries vis-à-vis general patients.
The amount of performance Bank Guarantee will be forfeited and the ESIC Shall have the right to
de-recognize the health Care Organization as the case may be. Such action could be initiated on the
basis of a complaint, medical audit or inspections carried out by ESIC teams at random. The
decision of the ESIC will be final.

IX. Liquidated Damages

(a) The empanelled Hospital, Diagnostic Laboratory/Imaging Centre shall provide the service as
per the requirements specified by the ESIC in terms of the provisions of this Agreement. In case of
initial violation of the provisions of the Agreement by the Hospital such as refusal of service or
direct charging from the ESIC Beneficiaries or defective service and negligence, the amount
equivalent to 15% of the amount of Performance Bank Guarantee will be charged as agreed
Liquidated Damages by the ESIC, however, the total amount of the Performance Bank Guarantee
will be maintained intact being a revolving Guarantee.
(b) In case of repeated defaults by the empanelled Hospital, Diagnostic Laboratory/Imaging
Centre, the total amount of Performance Bank Guarantee will be forfeited and action will be taken
for removing the Health Care Organization from the empanelment of ESIC as well as termination of
this Agreement.
(c) For over-billing and unnecessary procedures, the extra amount so charged will be deducted
from the pending/future bills of the empanelled Hospital, Diagnostic Laboratory/Imaging Centre and
the ESIC shall have the right to issue a written warning to the health care organization not to do so
in future. The recurrence, if any, will lead to the stoppage of referral to that particular Health Care
Organization or de-recognition from ESIC.

X. ARBITRATION
If any dispute or difference of any kind what so ever (the decision thereof not being otherwise
provided for) shall arise between the ESIC and the Empanelled
Hospital/Diagnostic Centre upon or in relation to or in connection with or arising out of the
services shall be settled by mutual discussions, and if not settled so then be referred for
arbitration by the Regional Director, ESIC, Bihar. The award of Arbitrator will be final and
 Page 10 of 22
binding. The provision of Arbitration and Conciliation Act, 1996 shall apply to the arbitration
proceedings. The venue of the arbitration proceedings shall be at the office of Regional Director,
Bihar. Any legal dispute shall be settled at court having jurisdiction in Bihar only.

XI. INDEMNITY

The Empanelled Hospital/diagnostic centre shall at all times, indemnify and keep indemnified
ESIC against all actions, suits, claims and demands brought or made against in respect of
anything done or purported to have been done by the Hospital/centre in execution of or in
connection with the services under this contract. and against any loss or damage to ESIC in
consequence to any action or suit being brought against the ESIC along with the Hospital/centre
or otherwise, as a part for anything done or purported to be done in the course of the execution of
this Contract. The Hospital/diagnostic center will at all times abide by the job safety measures
and other statutory requirements prevalent in India and will keep free and indemnify the ESIC
from all demands or responsibilities arising from accidents or loss of life resulting from
negligence or unreasonable conduct on the part of empanelled hospital/diagnostic centre. The
Hospital/diagnostic center will solely pay all the indemnities arising from such incidents without
any extra cost to ESIC and will not hold the ESIC responsible or obligated. ESIC may at its
discretion and always entirely at the cost of the tie up Hospital/diagnostic center defend such
suit, either jointly with the tie up Hospital or severally in case the latter chooses not to defend the
case.

XII. Risk and Cost

Patients cannot be denied treatment on the pretext of non availability of beds/ specialist etc. In
case of failure by the empanelled hospital to perform its duties under this contract due to
whatever reason, REGIONAL DIRECTOR, ESIC, Bihar has right to get the performance of
duties done from any other hospital at the sole risk and cost of the empanelled Hospital.

XIII. Criteria for De-empanelment

The Regional Director Bihar, without prejudice may terminate the empanelment for any breach
of contract by the empanelled hospital/Diagnostic centre. De-empanelment of the empanelled
Health Care Organization(s) could be made due to any one of the following reasons:
1. Rendering resignation/written unwillingness to continue in the panel.
2. Default (both actual and constructive) in fulfilling any term and condtion of the tender document in
the course of empanelment.
3. Due to unsatisfactory services and proven case of malpractice/misconduct/medical negligence.
4. Refusal of services to ESI beneficiaries.
5. Undertaking unnecessary procedures in patients referred for IPD/OPD management.

6. Prescribing unnecessary/drugs/tests while the patient is under treatment.

7. Over billing of the procedures/treatment/investigations undertaken.
8. Reduction in staff/infrastructure/equipment etc. after the hospital has been empanelled.
9. Non submission of the report, habitual late submission or submission of incorrect data in the report.
10. Refusal of credit to eligible beneficiaries and instead asking them to pay.
11. If not recommended by NABH/NABL at any stage.
 Page 11 of 22
12. Discrimination against ESI beneficiaries vis-à-vis general patients.
13. Death of owner/change of ownership, location of business place or the practice place, as the case
may be, if not approved by competent Authority.

14. If the owner gives the establishment on lease to other agency, they will be liable for de-
empanelment.

15. Charging any amount from the ESIC Beneficiaries or asking them to purchase medicine etc. from
outside.

XIV. Procedure for de-empanelment/blacklisting.

1. If any empanelled Health Care Organization is detected to be indulging in malpractice/
unethical practice/medical negligence or defaulter of any of he criteria listed in de-
empanelment, the matter will be got investigated by the REGIONAL DIRECTOR.
2. On receiving information of de-empanelment/ blacklisting of Health Care Organization(s) from
the CGHS/Railways/DGAFMS or any other Govt. Organization.
3. On receiving information in both cases listed out in paragraphs 1 and 2 above, the empanelled
facility will be given an opportunity to show cause before a decision for de-
empanelment/blacklisting is taken.
4. Based on the investigation report and examining the reply of show cause notice the
REGIONAL DIRECTOR.
5. Once any Health Care Organization is de-empanelled, MoU with that Health Care Organization
shall stand terminated from the date of de-empanelment. The de-empanelment Health Care
Organization will be debarred for empanelment for a period of one year.
6. If the Health care Organization is blacklisted the MoU with that Health Care Organization will
be debarred from empanelment for a period of three years.

XV. Re- empanelment of de-empanelment/blacklisted Health Care Organization (s)

1. The de-empanelled Health Care Organization (s) may be reconsidered for re-empanelment after one
year from the date of de-empanelment, if deficiencies are removed.
2. The blacklisted Health Care Organization ( S) may apply for empanelment only after expiry of three
years from the date the Health Care Organization was blacklisted.
3. The de-empanelment/blacklisted Health Care Organization shall apply as frest applicant for
empanelment only after expiry of the period of bar.
4. The re-empanelment/ blacklisted Health Care Organization will be considered as fresh applicant for
empanelment.

I/We have understood all terms and conditions of this document and particulars filled by me are true
and correct.

Signature of Applicant

Medical Superintendent/ Managing Director/ Proprietor

 Page 12 of 22
Annexure-II

APPLICATION FORMAT FOR EMPANELMENT OF HOSPITALS

A. Details of Hospital

1 Name of Hospital-

Name of the city where hospital

2
is located.

Address of the hospital

3

4 Telephone No.

5 Fax No.

6 E-mail Address

Name and Contact details of

7
Nodal person

Name

e-mail ID

Telephone no./Mobile no.

B. Details of NABH Accredition

1 Whether NABH Accredited

2 Whether NABH applied for

If NABH Accredited Certificate

3
No

C. Details of Cost of EOI Document

1 Amount
 Page 13 of 22

2 DD No

3 Date

Drawn on (Name of Bank)

D. Details of Services Applied for

1 1

2 2

3 3

4 4

E. Infrastructure Details
Total No. of Beds

No. of Beds in casualty in

1
Emergency

2 ICCU/ICU

3 Semi-private (2-3 bedded)

4 General ward bed (4-10 bedded)

5 Others

Average Bed of Occupancy for

6
last one year

7 Total Area of the Hospital

8 Area allotted to OPD

9 Area allotted to IPD

10 No. of Wards

Dimension of Ward
(Length*Breadth)

(Norms -Seven Square Meter

Floor area per bed required -)
(IS: 12433- Part 2:2001)
 Page 14 of 22
F. Basic amenities

Bedsides table

Wardrobe

Telephone

Alternate Power Source

G. Other amenities
Air Conditioner

T.V

Room Service

Any other

H. Nursing Care
Total No. of Nurses

Number of Para-medical Staff

Nurse ratio

A. General Ward (norm 6:1)

B. Semi-private ward (norm
4:1)
C. Private (norm 4:1)

D. ICU/ICCU (norm 1:1)

E. High dependency units
(norm 1:1)
I. Availability of Doctors
Number of Full time Medical
Officer

Number of Full time Specialist

Number of Full time Super

Specialist

Number of Super Specialist on

 Page 15 of 22

call

J. Laboratory Services
Pathology

Bio-chemistry

Hematology

Microbiology

Any other

K. Imaging Facilities Available

Give details

L. Operation theatre

Number of Operation theatre

Whether there is separate OT

Yes/No
for Septic cases

M. Supportive Services

Boilers/Sterlizers

Ambulance

Laundry

House Keeping

Canteen

Gas plant

Dietary

Other (Preferably)

a. Blood bank

b. Pharmacy

c. Physiotherapy
 Page 16 of 22

N. Waste Disposal System

Whether Waste Disposal
System Available as per Yes/No
Statutory requirements

O. Details of Hospital Bank Account

a. Name of Bank

b. Bank Branch

c. Account No

d. IFSC Code

e. MICR No.

Note:- Strike out which is not applicable

I/ We have understood all terms and conditions of this document and particulars
filled by me are true and correct.

SIGNATURE OFAPPLICANT

Medical Superintendent/ Managing Director/Proprietor

 Page 17 of 22

Annexure-III

APPLICATION FORMAT FOR EMPANELMENT OF DIAGNOSTIC CENTERS

1. Name of the Diagnostic Centre.

2. Name of the city where Diagnostic Centre is located.

3. Address of the Diagnostic Centre

4. Tel / Fax / E-mail

Telephone No.

Fax No.

E-mail Address

Name and Contact details of Nodal person

Whether NABL Accredited

Whether NABL applied for

Details of Accreditation and validity period (if applicable)

Details of the application fee of Rs 1000/-

Name & Address of the Bank Online Payment Date

Total turnover during last financial year (2020-2021) ----

(Certificate from Chartered Accountant is to be enclosed).

 Page 18 of 22

5. Availabilities of Doctors and staff

a. No. Radiologist
b. No. M.D Pathologist
c. No. M.D Microbiologist
d. No. of M.S(Anatomy)/Ph.D with [Link] (human Anatomy)/ Ph.D Genetics/ Ph.D (Applied
Biology)
e. No. of Technical staff

6. Waste disposal system as per statutory requirements Yes/No

7. Super Specialty/ Investigations applied for-

a. CT Scan
b. MRI
c. PET scan
d. Echocardiography
e. Scanning of other body parts
f. Specialized bio-chemical and immunological investigations
g. Any other investigation costing more than Rs. 3000/-test

Note-Strike out which is not applicable.

SIGNATURE OFAPPLICANT

Medical Superintendent/ Managing Director/Proprietor

p

Annexure-IV

CERTIFICATE OF UNDERTAKING

1. It is certified that the particulars given in the application form are correct and
eligibility criteria are satisfied.
2. That Hospital/ Diagnostic Laboratory/ Imaging centre shall not charges ESI
beneficiaries higher than the CGHS notified rates or the rates charge from other
patients who are not ESI beneficiaries.
3. That the rates have been claimed against a facility/ Procedure/investigation
actually available and performed at the Organization.
4. That if, any information is found to be untrue; Hospital/ Super Specialty
Diagnostic centre would be liable for de-recognition/ de-empanelment by ESIC.
The Organization will be liable to pay compensation for any financial loss caused
to ESI or physical and or mental injuries caused to its beneficiaries.
5. That the Hospital/ Diagnostic Centre has the capability to submit bills and
medical reports in digital format and that all billing will be done in electronic
format and medical records will be submitted in digital format.
6. The Hospital/ Diagnostic Centre will pay damage to the beneficiaries if any
injury, loss of part or death occurs due to gross negligence. The hospital is
responsible for managing the activities of its personnel and will hold itself
responsible for their misdemeanors, negligence, misconduct or deficiency in
services, if any.
7. That the Hospital/ Diagnostic centre have not been de-recognized by CGHS or
any State Government or any other organization in the last three financial years.
8. That no investigation by central Government/ State Government or any statuary
investigating agency is pending or contemplated against the hospital/ Diagnostic
centre.
9. I/ We agree for the terms and conditions prescribed in the tender document.
10. Hospital agrees to implement electronic medical records as per the standards
approved by Ministry of Health and Family Welfare, Government of India and
guidelines issued within one year of its empanelment.
11. I/ We also undertake to provide uninterrupted services otherwise alternative
arrangements will be made at the risk and cost of our institute.
12. I/ We also undertake not to deny treatment/ investigation to any patient referred
from ESI system and having entitlement for treatment as per ESI rules.
13. I/ We also undertake to observe the instructions of ESIC issued from time to time
in connection with services under the empanelment.
14. I/ We undertake to provide data/ information/ documents/ treatment papers in the
form and format as required by ESIC regarding Primary/ Secondary/SST
treatment of ESI beneficiary.

SIGNATURE OFAPPLICANT

Medical Superintendent/ Managing Director/Proprietor

p

Annexure-V

I/We submitting copies of the following documents

(wherever applicable) along with the tender-

1. Copy of legal status, place of registration and principal place of business of the health
care organization or partnership firm etc.
2. A copy of partnership dead/memorandum and articles of association, if any.
3. Copy of the license of running blood bank.
4. Copy of documents fulfilling necessary statutory requirements.
5. All documents mentioned in Terms and Conditions point III- copies of documents
required for Empanelment (a to o)

SIGNATURE OF APPLICANT

Medical Superintendent/ Managing Director/Proprietor