APPLICATION FORM

Cost of Form Rs.500/-(not-refundable)

Form No.
Form DD No/Receipt No

To,
The commissioner,
State Insurance & P.F. Department
(General Insurance&Mediclaim),
Vitta Bhawan,Janpath, Jaipur.

Sub:-Request for the empanelment of my hospital for mediclaim policies,

1. Name of the Hospital:

______________________________________________________________________
2. Address:
______________________________________________________________________
______________________________________________________________________
3. Ownership:
______________________________________________________________________
4. Year in which established:
______________________________________________________________________
5. Contact person(s):
(Please indicate [] with whom correspondence to be made)
Chief Executive Officer: (or equivalent)
Mr./Ms./Dr. ___________________________________________________________
Designation: __________________________________________________________
Tel: ___________________________ Mobile: _______________________________
Fax: _________________________________________________________________
E-mail: _______________________________________________________________
Empanelment Coordinator (if different from:5 above)
Mr./Ms./Dr. ___________________________________________________________
Designation: __________________________________________________________
Tel: ___________________________ Mobile: _______________________________
Fax: _________________________________________________________________
E-mail: _______________________________________________________________

6- (1) Registration Number of Hospital

(2) Registering Authority:-
(3) PAN Number of Hospital:-
(4) Payment to be made in favour of :-
(5) Bank & Bank a/c no.
(6 )if any toll free number:-
7. Annual Turnover for previous year:

8. Number of Indoor patient Beds: (number currently in operation) (please exclude emergency, day-care,
recoveryroom beds etc.

9-Bed Capacity:-

Signature with seal

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10- OPD
OPD DATA (Last three years) including Day Care cases
(i) 2007-08
(ii) 2008-09
(iii) 2009-10

11. IPD DATA (Last three years)

Period Number of Patients Admitted
(i) 2007-08
(ii) 2008-09
(iii) 2009-10

12. Scope of Empanelment (Clinical services being provided by the hospital)

Application is made as a (strike out which is not applicable)
(a). Multi Speciality (General Purpose Hospital)
i. Having more than 80 beds in Class A
ii. Having between 50 to 79 beds in Class B
iii. Having more than 30 to 49 beds in Class C

(b). Super speciality hospital (Indicate speciality from list below)

i. Having between 25 beds and above
(c). Day Care Centre having 10 or more beds with provision for overnight stay
for emergency
i. Eye Care
ii. ENT Care
iii. Specialised diagnostics
iv. Fertility regulation
(d). Diagnostic Laboratory
(e). Imaging Centre
(f) Clinical Service Provided (Yes/ No)
13. Number of Beds Available for
(i) Cardiology
(ii) Cardiothoracic Surgery
(iii) Coronary Care Unit
(iv) Day Care Treatment Endoscopy
(Diagnostic & Therapeutic)
(Yes/ No)
(v) Dentistry & Oral Surgery
(vi) Dermatology
(vii) Dialysis
(viii) Emergency Medicine & Surgery
(ix) Ear Nose and Throat
(x) Fertility Regulation
(xi) Gastroenterology
(xii) General Medicine
(xiii) General Surgery
(xiv) Gynaecology
(xv)
(a) Intensive Care Unit adult
(b) Intensive Care Unit paediatric
(c) Intensive Care Unit neonatal
Signature with seal

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 (xvi) Laser treatment
(xvii) Nephrology
(xviii) Neurology
(xix) Neurosurgery
(xx) Nuclear Medicine
(xxi) Obstetrics
(xxii) Oncology
(a) Medical Oncology
(b) Radiation Oncology
(c) Surgical Oncology
(xxiii) Ophthalmology
(xxiv) Orthopaedic Surgery
(xxv) Paediatric medicine & Paediatric Surgery
(xxvi) Plastic & Cosmetic Surgery
(xxvii) Physiotherapy & Rehabilitation Medicine
(xxviii) Respiratory Medicine
(xxix) Surgical ICU
(xxx) Transplantation Services Others, please state
14. Diagnostic Services being provided by Hospital (Yes/ No)
(i) Diagnostic Imaging:
(ii) CT Scanning
(iii) DSA Lab
(iv) Gamma Camera
(v) MRI
(vi) PET
(vii) Ultrasound
(viii) X-Ray- conventional
(ix) X-Ray- digital
15. Laboratory Services:
a. Clinical Bio-chemistry
b. Clinical Immunology
c. Clinical Microbiology
d. Clinical Pathology
e. Molecular Diagnostics
f. Blood Transfusion services
16. List Indoor patient Care Units/ Wards and the Number of each Unit/ Ward.
a. Name of Unit/ Ward Number of Wards
b. Number of Beds Floor/ Location
c. Private Wards (Single occupancy)
d. Semi Private Wards (2-3 patients occupancy)- AC
e. Semi Private Wards (2-3 patients occupancy)- Non-AC
f. General Wards(4-10 patients occupancy) AC
g. General Wards(4-10 patients occupancy) non AC
16. ICU,NICU,PICU,ITU,HDU, Any others
17. Non clinical and Administrative Departments
Support service In House or Out sourced
a. Catering
b. Cleaning services
c. General Administration
Signature with seal

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 d. Medical Records Keeping
e. Laundry
f. Pharmacy Services
g. Management of clinical waste
h. Management of nonclinical waste
i. Mortuary Services
j. Others( please specify)

18. Staff Information (attach a separate sheet with details )

(i) Doctors
a. Resident Doctors- regular appointment
b. Resident Doctors contractual
c. Resident Doctors- part time
d. Consultants (specialty wise)
1) Full Time
2) Part Time
(ii) Nurses
(iii)Technicians
(iv)Paramedical
(v) Others
19. Furnish the list of applicable Statutory/ Regulatory requirements by which the
organisation is governed by; including the rate lists for all services to be empanelled
under SIPF Deptt and what discount will be provided by your hospital on your rate lists..
______________________________________________________________________
______________________________________________________________________
20. Litigation, if any:
______________________________________________________________________
21. Any punitive measures taken against the Hospital or major partners within last five
years by any statutory authority/TPA /SIPF Deptt. If yes, please give details

22-Whether hospital is accredited by NABH? If yes then give the details:-

23-Purpose of empanelment:- (a) Rajmediclaim (b)SSABY (saras mediclaim)

(c) electric companies of Rajasthan (d) other (e) all of these schemes.
(please tick which you want)
Signature with seal

CERTIFICATE GIVEN BY AUTHORISED PERSON

I, ____________________, son/ daughter of _______________________ of
______________
do hereby affirm that the facts given above are true and if any discrepancy is detected at
a later date, the application form/ empanelment of my hospital may be rejected without
any further reference to me or my organisation.

Authorised Signatory
Name: ___________________________
Designation: ______________________

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Note:-

1. Please do not write ^^not applicable^^against facilities which your hospital does
not have,but write ^^not available^^.
2. Duly filled form is to be deposited within prescribed dates that is between
10th,june, 2010 to 20th,june,2010 along with required documents in sealed
envelope indicating “Application Form for Empanelment”in the office of the
Additional Director,General Insurance Fund,State Insurance & Provident
Fund,IInd Floor, D Block,Vitta-Bhawan,Janpath,Jaipur.
3. In case form is downloaded from our website http://sipf.rajasthan.gov.in, a
Demand Draft of Rs.500/- in favour of “Additional Director, General Insurance
Fund” is to be enclosed and should reach in this office latest by 20th,june,2010
during office hours.
4. In the rate list enclosed with the filled up form, discounts provided to this
department for different procedures of treatment should be clearly mentioned.
5. Seperate sheets can be enclosed for providing added information regarding
hospital facilities.
6. In case hospital is situated in more than one premise then the hospital
management will have to get empanelled its each branch separately.
7. Hospitals are being empanelled only for allopathic treatment.
8. Jurisdiction of all disputes will be at jaipur.

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