7.hospital registration application form

7/30/2019 7.Hospital Registration Application Form

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FORM - I[See Rule - 4(a)]

APPLICATION FOR REGISTRATION OF ANDHRA PRADESH ALLOPATHICPRIVATE MEDICAL CARE EXTABLISHMENT

1. Name & Address of the Allopathic Private :

Medical Care Establishment

2. Name of Correspondent or any Authorised :

person for correspondence

3. Name and address of the Society / Trust & :

date on which it was established

4. Whether the accommodation is owned by the :

establishment or on lease / rent. If so please

furnish the period of lease / rent along with the

documentary proof.

5. The date of establishment of Medical Care : a) Open Area b) Constructed Area

Establishment.

6. Total Area of establishment (One set of :photographs of the premises with its functional

areas to be furnished)

7. Bed Strength :

8. Types of Services offered : a) Basic b) Speciality

c) Super Speciality d) Diagnostics

9. Names of Doctors along with registration number :

allotted by MCI /APMC(Please enclose the details)

10. Names of qualified Nursing Staff, with :

their Registration numbers of NCI/any

other board. (Please enclose the details)

11. Names of Para Medical Staff & their :

Registration Numbers (List to be enclosed)

Cost : ` 1/-

(To be submitted in Duplicate)


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12. No. of supporting Staff (list to be enclosed)

13. No. of Specialists available. :

(Please enclose the details)

14. The List of Equipment and Furnisture available. :

(Please enclose the details)

15. Labour room with Pediatric care facilities. :

16. Operation Theatres :

17. Diagnostic Facilities including Clinical :

Laboratory and Imaging facilities.

18. Whether Registration is sought for main facility :

or branches also, if so details (Separate

application shall be submitted for each branch)

19. The Financial position of the Hospital/ Institute :

(enclose audit report of the last two years)

20. Any other information relating to Hospital :

21. Declaration on Stamp paper for willingness : Yes /Noto comply with the prescribed rules is enclosed.

22. Particulars of the Registration fee paid

(D.D No., Name of the Bank and

Date & Amount)

I here declare that the information furnished above is true to the best of my knowledge and belief and if it is found that

any wrong information is furnished or suppressed the material facts, I will take full responsibility for the consequential action

as per law.

(Signature)

(Name and Designation and full

address with official Seal)

Date:

Place:

:


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1. DISPLAY OF RATES :

a) The Establishment shall display the rates charged for each type of services provided by them for the benefit of the

patients at the reception counter in both the local and English language. The list of minimum services for which rates

are to be displayed are given in

Name of Service Type of Service Charges (in Rs.)

Room Charges: General Ward

(Includes Room / Bed Charges, Nursing Charges Private Rooms:

Medical Utilities Charges) Semi Deluxe - Shared

Deluxe with A/c.

Intensive Care Units: MICU & ICU

(Charges includes the ICU Bed Charges, Medical Utilities, NEURO

Monitoring and Nursing Charges) POW

Neonatal ICU

Pediatric ICU

OT Charges

General Anesthesia hour General Ward

Twin / Triple Sharing

General Anesthesia 1 hours General Ward

Twin / Triple Sharing

Local Anesthesia Hour

1 Hour

Surgical Procedure Charges (Package) : General Surgical Procedures

(Includes Surgeons Charges + Anesthetist Charges + Nursing Home Obstetric & Gynecology Procedures

Charges and inpatient medicines Charges) Orthopedic Surgical Procedures

Cardiac Surgical Procedure

Doctors consultation Charges: OP Other Super Speciality improved procedures

IP Per Visit

Emergency Visits Per Visit

Emergency Care Team Charges 3 Shifts per day

Diagnostic Charges

Common Diagnostic Tests X-ray per film

Ultra Sound, General and Obstetric Care Abdomen

Female Pelvic

KUB

CT Scan: Brain Plain

Multi Slice / Spiral / CT Scan Chest / Abdomen / Neck / Spine / OthersContract

MRI 0.5 / 1 / 1.5 Brain Plain

(Magnetic Resonance Imaging) Chest / Abdomen / Neck / Spine Others

Contrast

ECG / TMT / ECHO / EMG / EEG

Upper GI Endoscopy / Lower GI Endoscopy

Lab Investigations:

Random Blood Sugar

Blood Urea

Serum Creatinine

CBP / ESR / CUE

Blood Group

Blood for MPLFT

Lipid Profile

HBSAG / VDRL / HIV

Electrolytes

T3, T4, TSH

Note: Other Service Charges for Inpatients such as Drugs & Disposables, investigations and concessions, if any shall be

displayed at appropriate place for the benefit of the patient.

b) A copy of such list shall be sent to the Registration Authority by 1st June every year for record.

c) The Details of services and rates shall be explained to the patients or their attendants at the time of admission without

ambiguity


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SERVICES OFFEREDSl. No. Service Service Level Service Charges (`)

1 Extract of Adangal / Pahani 15 Minutes * 25/-

2 Extract of ROR 1B 15 Minutes * 25/-

3 Copy of FMB 15 Minutes * 25/-

4 Copy of Village Map 5 Days 35/-

5 F-Line Petitions 30 Days 35/-

6 Sub-Division of Lands 30 Days 35/-7 Mutation of Entries in Revenue Records 45 Days 35/-

8 Income Certificate 1st time - 7 days 2nd time & 35/-

thereafter - 15 minutes

9 Residence Certificate 1st time - 7 days 2nd time & 35/-


10 Integrated Certificate 1st time - 30 days 2nd time & 35/-

(Caste-Nativity-Date of Birth) thereafter - 15 minutes

11 OBC Caste Certificate 1st time - 30 days 2nd time & 35/-


12 EBC Certificate 1st time - 7 days 2nd time & 35/-


13 Agricultural Income Certificate 1st time - 7 days 2nd time & 35/-thereafter - 15 minutes

14 No Earning Member Certificate 1st time - 7 days 2nd time & 35/-


15 Family Member Certificate 1st time - 7 days 2nd time & 35/-

(Social Security Schemes & thereafter - 15 minutes

Govt. Employees / Pensioners)

16 Issue of Encumbrance Certificate Same day, if submitted by 2 pm 25/-

17 Certified Copy of Registration Document 15 minutes 25/-

18 Money Lending License Fresh - 45 days Renewal - 30 days 35/-

19 Allopathic Medical Care Registration 90 Days 35/-

20 Apathbandhu Scheme 10 Days 35/-

21 NFBS Application 1 Week 35/-

22 No Objection Certificate (Lands) 30 Days 35/-

23 Pawn Broker License Fresh - 45 days Renewal - 30 days 35/-

24 School Registration 1 Week 35/-

25 Birth Certificate - GHMC 15 Mins. (Category-A) 25/- per transaction + statutory charges

5/- per additional copy

26 Death Certificate - GHMC 15 Mins. (Category-A) 25/- per transaction + statutory charges

5/- per additional copy

27 Birth Certificate Corrections - GHMC 6 Working Days 60/- + 25/- per copy of certificate

28 Death Certificate Corrections - GHMC 6 Working Days 60/- + 25/- per copy of certificate

10/- + 25/- per copy of certificate

(after one year)

29 Child Name Inclusion - GHMC 6 Working Days 25/- per copy of certificate

(within one year)

30 Non Availability Certificate Birth - GHMC 3 Working Days 25/- per copy of certificate

NOTE :

1. Postal charges extra.

2. *Subject to availability of online digital records, otherwise the request will be processed within 7 days.

3. Printing of additional pages at ` 2/- per page.

1100 www.meeseva.gov.in

7.hospital registration application form

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