8/23/2019 Hospital Empanelment Form
EMPANELMENT FORM FOR
HOSPITALS/DAY CARE CENTRES
Healthcare unit should read below mentioned instructions carefully before filling the
empanelment form: • Kindly fill the empanelment form in english & block letters. • All the
fields marked with “*” needs to be filled mandatorily. • Healthcare unit shall be classified
based on the information provided in the form & RHIL reserves the right to physically
verify the fact by visiting the centers. • Kindly make sure that all the necessary documents
mentioned in the form are attached failing of which application shall be considered
incomplete. • All documents need to be duly signed & stamped. • Dispatch of filled form
& MOU does not confirm the empanelment of healthcare unit.
Basic Information
Hospital Name*
PARILOK HOSPITAL & RESEARCH CENTRE PVT. LTD.
Flat Building*
NH 74
Road/Street/Sector*
NAINITAL - DEHRADUN HIGHWAY
Area*
DHAMPUR
Taluka/Village/District/City*
BIJNOR
PIN Code*
246761
State*
UTTAR PRADESH
STD Code*
011
Landline number*
22437491
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Mobile*
9084093933
Email*
[Link]@[Link]
Fax*
22437491
Website*
[Link]
PAN*
AAICP9540M
Rohini ID.*
00
Nature of Service Provided (Please tick {√}the appropriate in case of
secondary/tertiary service)* −
Primary[Please specify the type*]
MULTISPECIALITY
Secondary/Secondary Plus
Single Speciality
Multispeciality
Tertiary/Tertiary Plus
Single Speciality
Multispeciality
Contact Information (Please provide correct information about the key
contact department)* −
TPA Desk/ Customer Care: Title
Mr
Contact Person
AKASH CHAUHAN
Designation
GENERAL MANAGER
Email
[Link]@[Link]
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Mobile
9084093933
Accounts / Finance:
Title
Dr
Contact Person
B K SINGH
Designation
DIRECTOR
Email
bksingh925@[Link]
Mobile
9319785299
Marketing / Business Development: Title
Dr
Contact Person
AKASH CHAUHAN
Designation
GENERAL MANAGER
Email
[Link]@[Link]
Mobile
9084093933
Fund Transfer Detail to be updated at: Title
Dr
Contact Person
B K SINGH
Designation
DIRECTOR
Email
bksingh925@[Link]
Mobile
9319785299
Evaluation Parameters(Please provide the appropriate information)* −
Bed capacity*:
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<15
15-40
40-100
>100
Please specify the active number of beds*
50
Hospital registration number*
ALP II 050
Number of registered beds*
50
Valid up to*
03/31/2020
Registering authority*.
CHIEF MEDICAL OFFICER BIJNOR
Only OPD Only IPD Type of facilities(Please tick{√} the correct one)*
Both OPD & IPD Casualty/Emergency 24*7 Doctor's Availability
In-patient facilities(Please tick{√} the correct one)*
Only Medical
Only Surgical
Medical & Surgical Both
Operation theater(Please mention count under each OT)*
General
Specialized
Labour Room
Intensive care unit(Please mention count of each type of ICU bed)*
Intensive Care Unit (ICU)
5
Intensive Critical Care Unit (ICCU)
2
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Surgical Intensive Care Unit (SICU)
3
Medical Intensive Care Unit (MICU)
5
Neonatal Intensive Care Unit (NICU)
10
Details of bed strength(Please specify the correct count)*
Bed/Room Name(As
[Link] Type Of bed* Total Count*
per hospital)*
A AC Suite DELUXE ROOMS 5
B AC Single PRIVATE ROOMS 10
C Non AC Single SEMI PRIVATE 10
D AC Twin Sharing
E Non AC Twin Sharing SEMI PRIVATE 10
Multi-Sharing (3-4
F
Beds)
General Ward (AC/ Non
G GENERAL WARD NON AC 10
AC)
ICU/ ICCU / MICU/
H ICU 5
SICU/ NICU
Other (Any specific type
I other than mentioned HDU 5
above)
Sterlization Practice (Please tick {✔} the correct one)*
Autoclaving
lonizing/Non-lonizing (UV) Radiations Antiseptics
Disinfectants Fumigation All of the Above
Medical services provided by the hospital(Please tick{√} the correct one)*
[Link] Type Of Service OPD IPD Monitoring Therapeutics
A Primary Care Service
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General Medicine/Internal
B
Medicine
C Pediatrics (Child-Care)
D Orthopedic (Bones & Joint)
E Ophthalmology (Eye)
F Ear, Nose & Throat (ENT)
G Gynecology & Obstetrics
H Cardiac (Heart)
I Neurology (Nervous System)
J Urology (Urinary Tract)
K Oncology (Cancer)
L Nephrology
General medicine/Internal
M
medicine
N Gastroenterology
O Other(Specialties if any)
Infrastructure and Other Details −
Property details(Please tick{√} the correct one)* Ownership of property*: A. Medico
Allopath
Ayurvedic
Homeopath
B. Non-medico:
Trust
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Mission
Private
Govt
Accreditation*:
NABH
ISO
JCI
NABL
Parking facility*:
Within Premises
Outside Premises
Not Available
Paid parking
Accessibility*:
Motor to Premises
Premise to Lift
By Trolly to Bed
Internal infrastructure details(Please tick{√} the correct one)*
[Link] Facility 24 hrs 12 hrs 6 hrs Less Than 4 hrs
A Water Supply
B Electricity
C Generator Back-up
D UPS for Critical Areas
E UPS for All Areas
Basic amenities(Please tick{√} the correct one)*
24 hrs Waiting Room
24 hrs Computerized Billing
Canteen for Patient Relatives
Patient Food Included in Accommodation
STD/FAX/Xerox Available
Direct Phone Access to Ward & ICU
Elevator Big Enough to Accommodate Trolley
lnhouse Services (Please tick {✔} the correct one)*
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[Link] Facility Strength Classification
A In-House Pharmacy
Hematology
Biochemistry
Microbiology
B Laboratory Pathology
Serology
Histopathology
Endocrine Lab
C Radiology/Imaging
X-Ray
Portable X-Ray
Ultra Sound
Colour Doppler
CT Scan
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MRI
General
Cardiac
D Ambulance Neonatal
Ventilator Support
Doctor Accompanying
E Cath lab
F Blood Bank
G Mortuary
H Dialysis Unit
Casualty
Emergency/Maintenance
I RTA Cases
Services
Cardiac Emergency
J Medical Record Management
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K Laundry/Security/Housekeeping
Full Time
L
Doctors/RMO’s/Nursing staff
OT description(Please tick{√} the correct one)* a) OT Table
i) Hydraulic
ii) Manual
b) Suction
c) Electrocautery
d) C-Arm/Boyle’s Apparatus
e) Cardic Monitor
f) Cardiac Defibrillator
Enclosures (Mandatorily to be submitted by the hospital)* −
Hospital Registration PAN Card Copy (In case payee name differs,
Certificate* attach both PAN Copies)*
Tariff Card/Rate-List* List of Consultants (OPD Schedule)*
Cancelled Cheque
NIL/Lower TDS Certificate (If Any)
(Original only)*
Service Tax Registration Doctor’s Registration Copy (If owned by a
Copy (If Any) Medico)
List of
Nursing/Paramedical Biomedical Waste Management Certificate
Staff
NEFT Declaration Form* Bank Statement Pass Book Copy*
NABH Registration Copy of Fire & Safety Department Clearance
Certificate* Certificate*
Information filled by(To be filled by the hospital)* −
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Name of the concerned person
AKASH CHAUHAN
Designation in the organisation
GENERAL MANAGER
Contact number
9084093933
I/we hereby declare that the information furnished in the given form is correct to
the best of my/our knowledge & belief. I/we fully understand that RHIL officials may
verify the information on this form & if any information furnished above, proved
incorrect or false will render me/us liable for any penal action or other
consequences as may be prescribed in law or otherwise warranted.
Place :
DHAMPUR BIJNOR
Date :
08/23/2019
Corporate and Registered Office: Reliance Health Insurance Limited, Reliance
Centre, 1st Floor North Wing, Santacruz (East) Mumbai - 400055. Customer Care
Number: 022 - 33426868 | Email: [Link]@[Link] | Website
: [Link]
Submit
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