EmpanelMent - Ayush Hospital Registration

Hospital Details Required

Name of the Hospital *

Address *

State *

District *

Contact Details Required

Designation *

Contact Person Name *

Mobile Number *

Landline Number *

Email Address *

Accreditation Details Required

Accreditation Type *

Upload Accreditation Certificate *

Valid From *

Valid Till *

Speciality & Empanelment Details Required

Speciality Type *

Empanelment Period From *

Empanelment Period Till *

Empanelment Status *

Details of Doctors Required

Doctor Name	Qualification	Registration Applicability	Registration No.	Validity	Employee Type	Action

Facility Details Required

Type of Facility / Hospital *

Number of Beds *

Lab Services Required

Lab Service Type *

Fire Safety Required

NOC for Fire Safety from Govt. Authority *

Building Approval Required

Building Plan Approval / Occupancy Certificate *

Clinical Establishment Required

Registration for Clinical Establishment Act *

X-Ray Services Required

X-Ray Services *

TAN / PAN Details Required

TAN / PAN Number *

Upload TAN / PAN Certificate *

GST Details Required

GST Applicability *

Bio-Medical Waste Management Required

Availability *

Name of CBWTF

Validity (Date)

Kitchen / Canteen Required

Availability *

Pharmacy / Medical Store Required

Type *

Ambulance Service Required

Service Type *

Bank Details Required

Bank Name *

Account Number *

IFSC Code *

Branch Address *

Lift Availability Required

Availability *

Application Fee (Rs. 5000/-) Required

Demand Draft Number *

Upload Demand Draft *

Undertaking Required

Download Undertaking Format
Download Format

Upload Signed 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. *

Application Form For Empanelment