Download Application Form for Recognition of Private Hospitals,Nursing Homes, Clinics and Pathological Laboratories for Treatment of J&K State Employees

APPLICATION FORM FOR RECOGNITION OF PRIVATE HOSPITALS, NURSING HOMES CLINICS & PATHOLOGICAL LABORATORIES FOR TREATMENT OF J&K STATE GOVT. EMPLOYEES To:- The Chief Medical & Health Officer District....................................Jammu and Kashmir Subject:-Application for recognition of private hospitals, nursing homes clinics & pathological laboratory for treatment of state govt. employees . Dear sir, I am submitting my application for recognition of my private hospital/, nursing home/ clinic/ pathological laboratory for treatment of state govt. employees. The particulars of my institution are given below. Name of Hospital/ Lab/Nursing Home/clinic ................................................................... Registration No ....................................................................................................... Address House No. ........... ward....................Mohalla......................Lane...................... Area..................... City................... Pin code................District...................... Jammu/Srinagar ( Please attach an approach map of the site ) Name of owner/Director.............................................Qualification................................ Telephone No................................................................ E-mail No............................ Year & Month of establishment .................................................................................. Registration details of institution under any other act ( PNDT, MTP, Sterilization scheme etc.) ..................................................................................................................... Was the institution ever recognised by state/ central Govt............................................... Whether Income tax return is filed ? IT No.................................................................. Audit certificates of last two years may be attached....................................................... Details of the Investigations / Procedures/ Services applied for recognition...................................................................................................................... ................................... Rate list/ Charges for investigations & Services with justification.......................................................................................................... ............................................................................................................................. Yearly report of Investigations / Procedures/ Services applied for recognition........................ ...................... .............................................................................................................................. Manpower position of the facility ( Names with qualifications & skills, attach separate sheet mentioning No. of trained & untrained staff/ Doctors/Specialists............................ ............................................................................................................................................... (Attach a map showing all facilities) Infrastructure details about building ( Attach Map)......................................................... Number of rooms, laboratories, Wards, Examination rooms, OPD rooms, Sp. Investigation rooms............................................................................................... .............................................................................................................................. Availability of floor space as per norm ........................................................................... What is the system of record keeping for patients. Is the stock register , Patient register indoor & out door investigation register maintained ? ( average patient related statistics may be shown).................................................................................................................... Are facility for emergency services available? ( Give details of Emergency equipments, drugs oxygen & resuscitation facilities)................. ................................................................................................................................. List of equipments available for the investigations/ examination, their make etc. ............................................................................................................................. Arrangements available for pathological & biochemical & Bacteriological investigations .......... ............................................................................................... Details of operation theatre, space, No. of rooms, autoclaving arrangements, Details of equipments, anesthesia used, and instruments availability, emergency light ............................................................................................................................. (this is required in case an operative procedure is requested for recognition)....................... Facilities available for dealing with emergency ............................................................. Any other information about your institution you want to give........................................... Date...................................... Signatures Name........................................... Place ..................................... DECLERATION FORM I ...................................... do hereby declare that the information given by me in the form is fully correct to the best of my knowledge & belief . I know that if any of the information is found fictious or incorrect the recognition of the institution will be cancelled . I also solemnly declare that I will charge the amount fixed by the Govt. for the Govt. employees. In case any amount higher than the Govt. approved rate is charged will be considered as the breach in the contract. I also declare that institution shall follow the rules & regulations under which the recognition is granted to the institution. Date...................................... Signatures Name..................................... Place ....................................