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Hospital/Provider Empanelment Request
Payer
*
Payer Scheme
*
Hospital/Provider Entity Name
*
Hospital/Provider Ownership
Corporate
Government
Semi-Government
Trust
Proprietary
Charitable Trust
Private Limited
Public Limited
Leased
Partnership
Private Public Partnership
Others
Hospital Speciality
*
Select Speciality
Single
Multiple
Hospital/Diagnostic Center/Autism Treating Center
*
HOSPITAL
DIAGNOSTIC CENTER
AUTISM TREATING CENTER
EAELY INTERVENTION CENTRE/DAY CARE CENTRE/SPECIAL SCHOOLS/REHABILITATION HOMES/OTHERS
Address (Site, Street, Area)
*
Hospital Type
*
Select Hospital Type
Medical College Hospital
Hospital
PHC
CHC
SHC
City/Location
*
Pincode
*
State
*
SELECT
ANDHRA PRADESH
KARNATAKA
KERALA
PONDICHERRY
TAMILNADU
TELANGANA
Landmark
District
*
Country
Telephone
*
Mobile
Fax
Email
*
Alternate Contact No.
Alternate Email Id
Alternate Communication Address
Web Address
NABH/GOI Standard
Yes
No
MD/CEO Name
*
MD/CEO Department
*
MD/CEO Mobile
*
MD/CEO Email
*
MD/CEO Fax
Select
MD
CEO
Row Number
Designation
Department
Name
Mobile
Email
Fax
1
Select Designation
MD
CEO
GM
DGM
Manager
Insurance Manager
Insurance Officer
Delete
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