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ROTHSHIELD HEALTHCARE (TPA) SERVICES LIMITED

Corporate Office: 402, Raheja Chambers, Nariman Point, Mumbai – 400021. India.

Tel: (022) 61123123 Fax: (022) 22854415 Website: www.rothshield.co.in

Date:

To,

Subject:

Empanelment of Your Esteemed Institution for our TPA Services

Dear Sir/Madam,

ROTHSHIELD HEALTHCARE (TPA) SERVICES LIMITED is a fast-growing Third Party Administrator (TPA) in the Indian Health Insurance Sector. We are licensed as a TPA by the IRDA of India (License No: 030). As a TPA, we are an important link between Insurance Companies, Policyholders & Healthcare Providers (Hospitals and Nursing Homes) to provide various services to all these different sectors of our Indian system.

We are offering the following services for Policyholders and Healthcare Providers:

←Cashless Hospitalization: We enter into agreements with Healthcare Providers to offer cashless and hassle free services to the Policyholders. Each Policyholder is provided with a list of our empanelled Healthcare Providers wherein he/ she can avail the cashless service.

←ID Card: We provide ID Cards to all our Policyholders in order to validate their identity during the course of admission in any of our panel Healthcare Providers.

←Claims Management: On behalf of the Insurance Companies, we adjudicate and settle claims for Healthcare Providers and Policyholders.

←24 Hour Customer Support Services: Rothshield (TPA) provides assistance through its 24 hours Call Center and also online access to the claims information regarding Policyholder’s data, Provider Network.

ROTHSHIELD HEALTHCARE (TPA) SERVICES LIMITED would like to enter into an agreement with your esteemed institution to offer “Cashless Hospitalization” to the Policyholders.

Please find attached a copy of our “Provider Agreement”, “Provider Information Form” and “Schedule of Charges”. We request you to send us back the “Provider Agreement” signed & stamped along with the “Provider Information Form” and “Schedule of Charges” duly filled as soon as possible. We will send you a copy of agreement duly signed by authorized signatory & various formats after receipt of the above documents from you.

We look forward to a long-term mutually beneficial relationship.

Regards

Authorized Signatory

Provider Department

This document is a copyright of Rothshield Healthcare (TPA) Services Limited © 2007 and contains information that is not to be copied, shared, disclosed or otherwise compromised without the written consent of Rothshield Healthcare (TPA) Services Limited

Page 0 of 15

MEMORANDUM OF UNDERSTANDING BETWEEN ROTHSHIELD HEALTHCARE (TPA) SERVICES LIMITED & HEALTHCARE PROVIDER

This Memorandum Of Understanding made at ___________ this ____________ day of

_____________ 200 .

BETWEEN

Rothshield Healthcare (TPA) Services Limited, a company incorporated under the Companies Act 1956 and having its Registered office at 106, Marine Chambers, 43, Sir Vithaldas Thackersey Marg, New Marine Lines, Mumbai-400020, India & Corporate Office: 402, Raheja Chambers, Nariman Point, Mumbai-400021, India or its associate company bearing the logo of Rothshield Healthcare (TPA) Services Limited herein referred to as Rothshield Healthcare (TPA) Services Limited, (which expression, unless it be repugnant to the context or meaning thereof, shall deem to mean and its successors and assigns) of ONE PART.

AND

_______________________________________________________________________, and having its Registered Office at ______________________________________hereinafter referred to as PROVIDER, (with Hospital Registration No.: ________________ and total ________ beds) which expression, unless it be repugnant to the context or meaning thereof, be deemed to mean and include its successors and assigns of the OTHER PART.

WHEREAS

Rothshield Healthcare (TPA) Services Limited, is an IRDA Licensed “Third Party Administrator (License No. 030)”, providing Healthcare related services to its beneficiaries and clients and for these purposes Rothshield Healthcare (TPA) Services Limited has created a network of service providers. _____________________________________________ is desirous to join the said network of providers and is willing to extend medical facilities and treatment to its members covered under various healthcare management plan on the agreed terms and conditions.

Now this agreement witnessed that:

Article 1: EFFECTIVE DATE

1.1The Parties hereby agree that the Effective date of the Agreement shall be the date on which the agreement is signed.

Article 2: INFRASTRUCTURE & FACILITIES WITH PROVIDER

2.1It is mandatory for the Provider to make the arrangements of dedicated Facsimile Telegraphy Equipment (Fax Machine) in premises for routine document communication with Rothshield Healthcare (TPA) Services Limited.

2.2The provider should possess the basic infrastructure of general ward, rooms for boarding, operation theatre, anesthesia facilities, surgical instruments, labour room, treating surgical consultant, resident doctor and trained nursing staff.

This document is a copyright of Rothshield Healthcare (TPA) Services Limited © 2007 and contains information that is not to be copied, shared, disclosed or otherwise compromised without the written consent of Rothshield Healthcare (TPA) Services Limited

Page 1 of 15

2.3The Provider will display the status of preferred provider for Rothshield Healthcare (TPA) and also display package rates of various surgeries covered in the scheme, procedure guidelines, and guide book in the poster format at the reception of the hospitals for the ready reference of the members of the scheme.

2.4The provider should have a contact person in case of the communication shall treat Rothshield Healthcare (TPA) Services Limited beneficiaries in a courteous manner and with good business practices.

2.5The Provider will extend priority admission facilities to the beneficiaries of the enrolled members of Rothshield Healthcare (TPA) Services Limited.

2.6The Provider will have his facility covered by proper indemnity policy including error, omission and professional indemnity and agrees to keep such policy in force during entire tenure of the agreement.

2.7The Provider shall ensure that best medical treatment / facility is extended to the beneficiary.

2.8The Provider shall endeavor to have an officer in the administration department assigned for insurance / contractual patients and the officer will have to lease the various types of medical benefits offered to the enrolled members of Rothshield Healthcare (TPA) Services Limited.

2.9The agreement is subject to the detailed schedule submitted by the provider in both Soft Format & Hard Format duly signed and stamped, which has to be agreed by Rothshield Healthcare (TPA) Services Limited.

2.10The Provider shall allow Rothshield Healthcare (TPA) Services Limited official to visit the beneficiary and also check the indoor papers/treatment being given to the beneficiary & whether the patient is comfortable with the services or not. However, Rothshield Healthcare (TPA) Services Limited shall not interfere with medical treatment of the patient. The medical team of Rothshield Healthcare (TPA) Services Limited reserves the right to discuss the treatment plan with treating doctor. Access to billing, medical records and indoor papers will be allowed to Rothshield Healthcare (TPA) Services Limited as and when necessary or asked for with request letter from Rothshield Healthcare (TPA) Services Limited.

2.11The Provider agrees to comply with statutory requirement and follow the law of land. The Provider shall also agree to comply with future requirements of insurer like standardized billing, ICD-10 coding etc. In case the provider doesn’t have such facility at their end, they shall agree to get such things out sourced by the outside agency at their own cost, as and when required.

2.12The Provider agrees to have medical audit/bills audit on periodical basis as and when

necessary with Rothshield Healthcare (TPA) Services Limited audit team.

This document is a copyright of Rothshield Healthcare (TPA) Services Limited © 2007 and contains information that is not to be copied, shared, disclosed or otherwise compromised without the written consent of Rothshield Healthcare (TPA) Services Limited

Page 2 of 15

2.13Rothshield Healthcare (TPA) Services Limited, will induct a team from the provider with the complete details of the process and procedures of pre-authorization of cashless and submission of the claim documents to Rothshield Healthcare (TPA) Services Limited. The provider will follow the guidelines and assure the implementation of the process and procedures.

2.14The Provider will instruct their attending consultant to keep the beneficiaries only for the required number of days of treatment and carry out only the required surgery for the ailment, for which he is admitted and covered under the scheme. Any other incidental investigation / procedures / treatment specifically required by patient for his benefit other than covered in the scheme, are not payable by insurer / TPA. The provider will not charge more than the package rates agreed by both the parties.

Article 3: IDENTIFICATION OF BENEFICIARIES

3.1All the guidelines for related to treatment should be as per the format mentioned in this agreement.

3.2The beneficiaries will be identified by the provider on the basis of the ID cards issued by Rothshield Healthcare (TPA) Services Limited.

3.3The beneficiaries will be identified by the provider on the basis of the alternate photo ID proof such as Voter ID Card, Passport, Driving License, PAN Card and Employer ID Card (only applicable for Government organizations and Public Limited Companies).

3.4For the ease of beneficiary, the provider shall display the recognition and promotional material, network status and procedures for admission supplied by Rothshield Healthcare (TPA) Services Limited at prominent location, preferably at the reception and admission counter and Casualty / Emergency departments. A provider also needs to inform their reception and admissions counter regarding the procedures of admission and obtaining Pre-authorization.

3.5Provider will take a photocopy of the ID card, to be submitted later with the bill or to keep as proof of the beneficiary being treated.

Article 4: PROVIDER SERVICES – ADMISSION PROCEDURE

A)INPATIENT TREATMENT:

B)PLANNED SURGICAL ADMISSION:

4.1Request for hospitalization on behalf of the beneficiary may be made by the provider/consultant attached to the provider, or beneficiary himself after obtaining due details from the treating doctor in the prescribed format i.e. “Request For Authorization Letter” (RAL). The RAL needs to be faxed to the Authorization Department at Rothshield Healthcare (TPA) Services Limited with Telephone/Mobile/Contact details of treating doctor. The complete information should be given to the beneficiary, as it would ease the process in the cases where the symptoms are vague or if effective diagnosis is not arrived at. The medical team of Rothshield Healthcare (TPA) would get in touch with treating physician/beneficiary, if necessary.

This document is a copyright of Rothshield Healthcare (TPA) Services Limited © 2007 and contains information that is not to be copied, shared, disclosed or otherwise compromised without the written consent of Rothshield Healthcare (TPA) Services Limited

Page 3 of 15

4.2Rothshield Healthcare (TPA) Services Limited guarantees payment through a Authorization Letter, on the receipt of RAL and the necessary medical history and investigation details. Rothshield Healthcare (TPA) Services Limited shall issue the Authorization Letter after ascertaining the eligibility of coverage.

4.3In case the ailment is not covered or given medical data is not sufficient for the medical team of helpdesk to confirm the eligibility, Rothshield Healthcare (TPA) Services Limited can deny giving the Authorization.

4.4Incase of the DL (denial Letter) from Rothshield Healthcare (TPA) Services Limited, the treatment charges should be recovered from the patient.

4.5AL will mention the amount guaranteed and eligibility of beneficiary as per the package rates agreed by the Provider, as per the benefit plan of the insured. Provider must see that the mutually agreed package charges are strictly followed.

4.6The guarantee of payment is given only for the surgical treatment cost of the ailment covered and mentioned in the request for hospitalization. Non-covered items like Telephone usage; relative’s food, hospital registration fees etc. must be recovered directly from the insured. Any Investigation carried out at the request of the patient but not forming the necessary part of the treatment must also be collected from the patient.

4.7The AL normally mentions the amount as per the rates agreed mutually, which is requested at the time of request for hospitalization. Any further complications during the course of treatment will be handled by the provider in the same package charges, as agreed by the provider. The provider will not charge any extra amount from the patient in such cases.

4.8Rothshield Healthcare (TPA) will not be liable for payments in case the information provided in the “Request for Authorization Letter” and subsequent documents during the course of authorization, is found incorrect or not disclosed.

C) EMERGENCY ADMISSION

4.9In case of other emergencies, the provider should call up the helpdesk of Rothshield Healthcare (TPA) Services Limited for Authorization. Rothshield Healthcare (TPA) Services Limited may continue to discuss the case with the treating doctor till conclusion of eligibility of coverage is arrived at. Provider in the meanwhile may consider treating the patient by taking a token deposit or as per their norms.

4.10If AL is issued after ascertaining the coverage, provider should refund the deposit amount if taken as a token, at the time of emergency admission.

Article 5: FEE SCHEDULE

5.1Provider has to submit the acceptance of fee schedule in the format designed by Rothshield Healthcare (TPA) Services Limited.

5.2The surgical package rates agreed upon mutually include stay during the hospitalization, medicines, consumables, surgical fees, operation theatre etc. No additional payment would be entertained for any deviation. The provider assures to

treat the patient in case of post operative complications in the package rates only.

This document is a copyright of Rothshield Healthcare (TPA) Services Limited © 2007 and contains information that is not to be copied, shared, disclosed or otherwise compromised without the written consent of Rothshield Healthcare (TPA) Services Limited

Page 4 of 15

5.3The provider will not charge from the patient in the bill or at actual more than the prescribed package rates as per the agreement. In case the provider charges more than the prescribed rates as per the agreement, the provider will refund the excess amount charged to the patient, and the provider will be de-empanelled from Rothshield Healthcare (TPA) network without any prior notice.

5.4Any revision in the fee schedule will be not be applicable and entertained by Rothshield Healthcare (TPA) Services Limited.

5.5Provider agrees that the schedule of fees agreed up on mutually is the lowest and if any other schedule of fees during the tenure is found lower than mutually agreed, Provider will refund such additional charges levied on Rothshield Healthcare (TPA) Services Limited.

5.6Provider would be happy to give a further discount on schedule of fees as given below, for the benefits of the beneficiaries taking the treatment in the premises:

1.

Bed Charges

________%

2.

OT Charges

________%

3.

ICU/ICCU Charges

________%

4.

Investigations Charges

________%

5.

Consultation Charges

________%

6.

Nursing Home

________%

7.

Surgery Charges

________%

8.

Medicines / Drugs

________%

 

OR

 

9.

Total Bill Discount of 20% on the package charges agreed upon mutually.

Article 6: DUTIES / CHECKLIST FOR THE PROVIDER AT THE TIME OF PATIENT DISCHARGE

6.1Original discharge card, original investigation reports, all original prescriptions & pharmacy receipt etc. must not be given to the patient. These are to be forwarded to billing department who will compile the same and forward along with the bill to Rothshield Healthcare (TPA) Services Limited

6.2In case the patient requires the Discharge card / reports, he/she can be asked to take photocopies of the same at his own expenses.

6.3The Discharge card / Summary must mention the duration of ailment, stay and duration of other disorders like hypertension or diabetes and operative notes in case of surgeries. The clinical details should be sufficiently informative.

6.4Signature or the thumb impression of the patient / beneficiary on final hospital bill including doctor’s daily visit charges, surgical fees etc. must be obtained.

6.5Claim form of the Insurance company / Rothshield Healthcare (TPA) must be presented to the beneficiary for signing and identity of the patient needs to be ascertained.

This document is a copyright of Rothshield Healthcare (TPA) Services Limited © 2007 and contains information that is not to be copied, shared, disclosed or otherwise compromised without the written consent of Rothshield Healthcare (TPA) Services Limited

Page 5 of 15

Article 7: BILLING PROCEDURE

7.1Final bill should be submitted to Rothshield Healthcare (TPA) Services Limited preferably in the format as submitted in Rothshield Healthcare (TPA) “Provider Servicing Kit” within

7 days from the date of the discharge.

7.2The bills must be as per the mutually agreed schedule of charges as provided along with this agreement in soft format and hard format both. Any higher amount charged by the provider will not be paid and will be deducted from the bill amount.

7.3Any non-covered treatment/ Investigation, cost must be recovered from the patient.

7.4The final docket for onward submission to Rothshield Healthcare (TPA) Services Limited for immediate payment must contain the following.

Copy of Rothshield Healthcare (TPA) ID card or Photo Document.

Copy of AL with Beneficiary’s Signature.

Signed Claim Form of the respective Insurance Company.

Original final bill with detailed break up of miscellaneous, consumables & other charges.

Original and complete Discharge Card mentioning duration of ailment and duration of other disorders like hypertension or diabetes if any.

Original Investigation reports with corresponding prescription / request.

Pharmacy bill, if supplied by hospital with corresponding request.

Any other documentary evidence, statutory under law.

Status of deposit paid if any, by beneficiary.

Any other related documents.

Article 8: PAYMENT TERMS & CONDITIONS

8.1Provider with furnish the Bank Account Details, like a/c Name, a/c number, name of the Bank, Branch and City, so that Rothshield Healthcare (TPA) will have the facilities of transferring the billed amount directly to the provider’s a/c.

8.2Rothshield Healthcare (TPA) agrees to pay all the eligible bills, within 30 days of the receipt of bill at their head office address in Mumbai.

8.3In case certain billed items are not correlated with corresponding report, such amount will be deducted from the final bill. However, the provider may send these reports within 90 days of receiving the payment to get the deducted amount with valid clarifications.

8.4Provider can instruct with proper request letter to Rothshield Healthcare (TPA) Services Limited to pay the amount separately to its vendor’s like pharmacies, diagnostic centers, ICD-10 coding vendor etc.

8.5Payment will be done by “At par payable” Cheque of Nationalized Bank/Electronic Transfer directly to provider’s bank account.

This document is a copyright of Rothshield Healthcare (TPA) Services Limited © 2007 and contains information that is not to be copied, shared, disclosed or otherwise compromised without the written consent of Rothshield Healthcare (TPA) Services Limited

Page 6 of 15

8.6Payment and bank deposition would be construed as due receipt, if a provider agrees to send a stamped receipt of the payment received immediately on receipt of the Cheque.

Article 9: LIMITATIONS OF LIABILITY AND INDEMNITY

9.1Rothshield Healthcare (TPA) Services Limited will not interfere in the treatment and medical care provided to its beneficiaries. Rothshield Healthcare (TPA) will not be in any way held responsible for the outcome of treatment or quality of care provided by the provider.

9.2Rothshield Healthcare (TPA) Services Limited shall not be liable or responsible for any acts of omission or commission of the Doctors and other medical staff of the provider.

9.3The Provider shall alone be liable to pay any costs, damages and / or compensation demanded by the beneficiary for poor, wrong or bad quality of the test report or treatment given to the beneficiary by the provider while executing any assignment of Rothshield Healthcare (TPA) Services Limited

Article 10: CONFIDENTIALITY

10.1The Provider undertakes to protect the secrecy of all the data of Rothshield Healthcare (TPA) Services Limited beneficiary and trade or business secrets of Rothshield Healthcare (TPA) Services Limited and shall not share the same with any unauthorized person for any reason whatsoever with or without any consideration and/or part the copies of the documents to anyone.

Article 11: TERMINATION

Rothshield Healthcare (TPA) Services Limited shall reserve the right to terminate the agreement without notice if-

11.1The provider violates any of the terms and conditions of this agreement; or

11.2Charges the patient more than the schedule agreed upon mutually, without prior notice; or

11.3Rothshield Healthcare (TPA) Services Limited comes to know of wrong and fraudulent practices, Rothshield Healthcare (TPA) hold the right to terminate this agreement with a letter of notice.

11.4Either party reserves the right to inform public at large along with the reasons of termination of the agreement by the method which they deem fit.

Article 12: NON – EXCLUSIVITY

12.1Rothshield Healthcare (TPA) Services Limited reserves the right to appoint any other provider for implementing the packages envisaged herein and the provider shall have no objection for the same.

This document is a copyright of Rothshield Healthcare (TPA) Services Limited © 2007 and contains information that is not to be copied, shared, disclosed or otherwise compromised without the written consent of Rothshield Healthcare (TPA) Services Limited

Page 7 of 15

Article 13: OTHER SERVICES OF ROTHSHIELD HEALTHCARE (TPA)

13.1Provider is free to choose Rothshield Healthcare (TPA) Services Limited to provide other various services on agreed financial terms, which are outside the contract between the insurer and insured and hence outside the preview of regulation. These services could include replenishing of certain consumables, imparting web space at web portal, software data entry and coding services etc.

Article 14: JURISDICTION

14.1Any Disputes / Claim arising out of this Memorandum of Understanding are subject to Arbitration and Jurisdiction of Mumbai Courts.

14.2In case of any dispute or differences arising out of this Memorandum of Understanding, each party may as soon as practicable give to other party notice in writing of the existence of such questions or disputes specifying its nature and the point of issue. If the parties cannot resolve the matters by a mutually acceptable solutions within 15 (fifteen) business days, the said dispute or difference shall be referred to and settled by arbitration under the provisions of the Arbitration & Conciliation Act, 1996 or any reenactments or modifications thereof.

14.3The sole Arbitrator shall enter upon the reference immediately and within 30 working days from its constitution pass the final award. The time of 30 days contemplated may be extended by mutual consent of both the parties in writing.

14.4The venue of the Arbitration shall be Mumbai and the arbitration shall be carried out in English language only.

14.5The arbitration decision shall be final, irrevocable and binding on all parties. The decision shall also determine the expenses of the arbitration and the Party shall bear them or the proportion of such expenses to be borne by each party.

14.6Any amendments in the clauses of the Agreement can be effected as an addendum, after the written approval from both the parties.

In witness thereof this agreement was executed by or on behalf of the parties the day and year first before written.

This document is a copyright of Rothshield Healthcare (TPA) Services Limited © 2007 and contains information that is not to be copied, shared, disclosed or otherwise compromised without the written consent of Rothshield Healthcare (TPA) Services Limited

Page 8 of 15

Signed and delivered by the within named:

 

Provider Signature:__________________

Witness Signature: __________________

Name: _____________________________

Name: ____________________________

Designation: ________________________

 

Address: ___________________________

Address: ___________________________

___________________________

___________________________

Hospital Seal:

___________________________

The Rothshield Healthcare (TPA) Services Limited

Signature: _________________________

Witness Signature: ___________________

Name: _____________________________

Name: _____________________________

Designation: ________________________

 

Address: ___________________________

Address: ___________________________

___________________________

___________________________

Rothshield Healthcare (TPA) Seal:

___________________________

This document is a copyright of Rothshield Healthcare (TPA) Services Limited © 2007 and contains information that is not to be copied, shared, disclosed or otherwise compromised without the written consent of Rothshield Healthcare (TPA) Services Limited

Page 9 of 15

HOSPITAL / NURSING HOME - PROVIDER INFORMATION FORM

1. General Information:

IPD&OPD

 

Daycare Unit

 

 

Type of Hospital:

_____________________________________________________________

1.1 Hospital Name: _____________________________________________________________

1.2 Hospital Address: _____________________________________________________________

(With Landmarks)

_____________________________________________________________

City: ________________________________ Pin: ___________________

District: _______________________ State: _________________________

1.3 Telephone Numbers: ( 0_____) 1. _________________ 2. ______________ 3. _________________

(With STD Codes)

4.__________________ 5. ______________ 6. _________________

1.4Fax Numbers: (0______) 1. _________________ 2. ______________ 3.__________________

1.5 Website: www.____________________________________

1.6 Email ID’s:

@

1.7Bank Account No. : ________________________________ Bank ______________________________

Branch: _______________________ Bank Account Name: __________________________________

1.8Key Contact Persons: 1. NAME: ________________________________________________________

Designation: _____________________ Telephone:_________________ Mobile: ________________

2. NAME: _________________________________________________________

Designation: _____________________ Telephone:_________________ Mobile: ________________

1.9 Billing Department: 1) _______________________________________Designation:_____________

2) _______________________________________Designation:_____________

2.0 Schedule of Charges Attached: [A] Yes / No

[B] Hard copy / Soft Copy

2.1Hospital Registration Number: ________________________________________________________

2.2Registration Authority: _____________________________________________________________

This document is a copyright of Rothshield Healthcare (TPA) Services Limited © 2007 and contains information that is not to be copied, shared, disclosed or otherwise compromised without the written consent of Rothshield Healthcare (TPA) Services Limited

Page 10 of 15

HOSPITAL INFRASTRUCTURE AND SERVICES DETAILS

(To be filled up by Hospital) (For Internal Use)

Beds

1 Total Number of Beds

2Number of ICU Units Number of ICU Beds

3Number of ICCU Units Number of ICCU Beds

4Number of NICU Units Number of NICU Beds

5Av. Bed Occupancy Ratio (In % for a year)

Please Attach Sheets for additional details

 

Medical Staff

(To be filled up by Hospital)

(For Internal Use)

1

No. of R.M.O.’s

 

 

2

No. of Resident Specialists

 

 

3

No. of Visiting Consultants

 

 

 

Laboratory Facilities

 

 

1

Pathology Test Facilities

 

 

 

available.

 

 

 

 

 

 

24 Hrs (Yes / No)

 

 

2

Biochemistry Test Facilities

 

 

 

available

 

 

 

 

 

 

24 Hrs (Yes / No)

 

 

3

Microbiology Test Facilities

 

 

 

available

 

 

4

Specialty Test Facilities

 

 

 

 

 

 

 

Imaging Facilities

(To be filled up by Hospital)

(For Internal Use)

1

Details of Radialogy Test

 

 

 

facilities

 

 

 

Is Portable available

 

 

2

Details of Sonography Test

 

 

 

facilities

 

 

 

Is Portable available

 

 

3

CT Scan Facilities

 

 

4

MRI Facilities

 

 

Please attach details of Equipments, Models etc.

 

Ambulance Services

(To be filled up by Hospital)

(For Internal Use)

1

Ambulance Van

No:

Own:

 

2

Cardiac Ambulance

No:

Own:

 

3

Ambulance for Neonatal

No:

Own:

 

This document is a copyright of Rothshield Healthcare (TPA) Services Limited © 2007 and contains information that is not to be copied, shared, disclosed or otherwise compromised without the written consent of Rothshield Healthcare (TPA) Services Limited

Page 11 of 15

 

Operation Theatres

 

(To be filled by Hospital)

(For Internal Use)

1

Minor Operations

 

No

 

 

 

2

Major Operations

 

No

 

 

 

3

Cardiac Surgeries

 

No

 

 

 

4

Neurosurgery

 

No

 

 

 

5

Orthopedics

 

No

 

 

 

6

Urology

 

No

 

 

 

 

 

 

 

 

O T Facilities

 

(To be filled by Hospital)

(For Internal Use)

1

OT Table

 

No

 

 

 

2

OT Lamp

 

No

 

 

 

3

OT General Instruments

 

No

 

 

 

4

OT Equipments

 

No

 

 

 

5

OT Monitors

 

No

 

 

 

6

Boyle’s Apparatus

 

No

 

 

 

7

Other Advanced

 

No

 

 

 

 

Instruments / Equipments

 

 

 

 

 

 

Please attach details of OT Instruments, Equipments, Models etc.

 

 

 

 

 

Medical Services

 

(Hospital Needs to Fill)

(For Internal Use)

 

 

 

 

STATE AS YES OR NO

 

 

1

Casualty

 

 

 

 

2

Cardiology

 

 

 

 

3

Cardiovascular

 

 

 

 

4

Thoracic Surgery

 

 

 

 

5

Respiratory System

 

 

 

 

6

Upper GI Open Surgery

 

 

 

 

7

Lower GI Open Surgery

 

 

 

 

8

Upper GI Endo-scopy Surgery

 

 

 

 

9

Lower GI Endo-scopy Surgery

 

 

 

 

10

Urology

 

 

 

 

11

Neurosurgery

 

 

 

 

12

Pediatric Surgery

 

 

 

 

13

Pediatric Medical

 

 

 

 

14

Neonatology

 

 

 

 

15

Nephrology

 

 

 

 

16

Neurology

 

 

 

 

17

Medical Intensive Care

 

 

 

 

This document is a copyright of Rothshield Healthcare (TPA) Services Limited © 2007 and contains information that is not to be copied, shared, disclosed or otherwise compromised without the written consent of Rothshield Healthcare (TPA) Services Limited

Page 12 of 15

For Single Specialty Hospitals

 

Supportive Services

(To be filled by Hospital)

(For Internal Use)

 

 

STATE AS YES OR NO

 

1

Blood Bank

 

24 Hrs: Yes / No

 

2

Pharmacy Services

 

24 Hrs: Yes / No

 

3

Boilers/Sterilizers

 

 

 

4

Physiotherapy

 

 

 

5

Generator Back Up

 

 

 

 

For all Critical Units:

 

 

 

 

For other Hospital Area:

 

 

 

6

Laundry Facilities

 

 

 

7

House Keeping

 

 

 

8

Canteen Facilities

 

 

 

9

Gas Plant

 

 

 

10

Waste Disposal System

 

 

 

 

 

 

 

 

 

 

 

 

 

Record Maintenance

(To be filled by Hospital

(For Internal Use)

 

 

State as Yes or No

 

 

 

 

 

 

1

Computerized Billing

 

 

 

 

24 Hrs (Yes / No)

 

 

 

 

 

 

 

 

2

Has the Hospital

 

 

 

 

implemented HIS

 

 

 

 

(Attach Details separately)

 

 

 

3

Has the Hospital

 

 

 

 

implemented the Diagnosis

 

 

 

 

and Procedure Codes?

 

 

 

 

(Attach Details separately

 

 

 

 

 

 

 

 

 

(To be filled by Hospital)

(For Internal Use)

1No. of Surgeries in 2006-07

a)Minor Surgeries

b)Major Surgeries

(Please give details of specialties separately)

For Other Specialties use separate sheets in following formats

All above information is true and correct.

Hospital Seal:

Sign of Hospital Authority

This document is a copyright of Rothshield Healthcare (TPA) Services Limited © 2007 and contains information that is not to be copied, shared, disclosed or otherwise compromised without the written consent of Rothshield Healthcare (TPA) Services Limited

Page 13 of 15

Kindly furnish the details for NEFT transfer for speedy remittance -

Name as mentioned in the bank account:

Account Number:

Name of the Bank:

Branch Name:

Branch Serial No.:

Address of the Bank Branch:

IFSC Code of the Bank Branch:

PAN No.:

Also, request to please enclose copy of PAN CARD.

Thanking You in Advance,

This document is a copyright of Rothshield Healthcare (TPA) Services Limited © 2007 and contains information that is not to be copied, shared, disclosed or otherwise compromised without the written consent of Rothshield Healthcare (TPA) Services Limited

Page 14 of 15

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