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Hospital/Provider Empanelment Request
Kindly fill all the mandatory columns.
  • Kindly fill Hospital management structure in the columns provided. The options for MD / CEO/ GM / DGM / Manager / Insurance coordinator / Insurance provider all these details should be submitted.
  • Bank details including PAN, IFSC code is mandatory. PAN card should upload in JPEG / PDF format.
  • Kindly provide details of specialities available at your hospital by choosing “ADD / SAVE SPECIALITY INFO”.
  • For each speciality please provide the details of all available specialist concerned.
  • It is mandatory to criteria.
  • ICU details for each speciality to be filled only if speciality ICU is available.
  • The details of intensivist and ICU personnel are mandatory.
  • The details of DMO (Duty Medical Officer) who are incharge in ward causality, ICU’s etc.. must be provided.
  • The details of Technicians, Ambulance paramedics, staff nurses and other medical personnel.
  • The registration numbers, other practicing hospital details must be mandatorily provided.
  • The registration and speciality certificate along with a undertaking form the doctor mentioning the hospitals or clinics (Hospital district must be mentioned) he / she tied up must be uploaded in single PDF.
  • The RC book copy and Chaise number of the Ambulance must be uploaded.
  • The empanelment criteria must be filled.
  • Please take screenshots of the application form while entering your Hospital / Diagnostic details in each stage and finally upload in PDF format with authorised sign and seal.