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Payer
*
Payer Scheme
*
Jyothi Sanjeevini
Cochlear Implantatio
Ayushman Bharat- Arogya Karnataka
Organ Transplant
RARE DISEASE
RBSK
.
Provider Entity Name
*
Hospital/Provider New?
Existing
New
Provider Type
*
BLOOD BANK
DIAGNOSTIC CENTER
HOSPITAL
PHARMACY
Hospital/Provider Ownership
*
Select
Corporate
Government
Semi-Government
Trust
Proprietary
Charitable Trust
Private Limited
Public Limited
Leased
Partnership
Hospital Type
*
Address (Site, Street, Area)
*
City/Location
*
Pincode
*
District
*
Select District
ANANTHPUR
BAGALKOTE
BALLARI
BELAGAVI
BENGALURU
BENGALURU RURAL
BIDAR
CHAMARAJANAGARA
CHIKKABALLAPURA
CHIKKAMAGALURU
CHITRADURGA
DAKSHINA KANNADA
DAVANAGERE
DHARWAR
GADAG
HASSAN
HAVERI
HYDERABAD
KALABURAGI
KARNOOL
KODAGU
KOLAR
KOLHAPUR
KOPPAL
LATUR
MANDYA
MYSURU
RAICHUR
RAMANAGARA
SANGLI
SHIVAMOGGA
SOLAPUR
TUMAKURU
UDUPI
UTTARA KANNADA
VIJAYANAGARA
VIJAYAPURA
YADGIR
Taluk
*
Landmark
State
Country
Telephone
*
Mobile
Fax
*
Email
*
Alternate Contact No.
Alternate Email Id
Alternate Communication Address
Web Address
MD/CEO Name
*
Mobile
*
MD/CEO Email
*
Fax
Medical Care Establishment Registration Details
*
Registration Number
*
Registration Date (dd/MM/yyyy)
*
Expiry Date (dd/MM/yyyy)
*
Registration Doc (PDF/DOC/JPG)
*
Declaration form (PDF/DOC/JPG)
*
Hospital Photo (PDF/DOC/JPG)
*
Health Facility Registry (HFR)
*
OTHER INFO or ACCREDITATIONS AND CERTIFICATIONS
OTHER INFO or Accreditation or Certification
Effective Date (dd/MM/yyyy)
Upload File
AERB DOCUMENTS
BUILDING PERMIT CERTIFICATE
DIESEL GENERATOR SET
ELECTRICAL SAFETY LICENSE
FIRE SAFETY LICENSE/NOC
KPME CERTIFICATE
LIFT LICENSE
NABH CERTIFICATE
ORGAN TRANSPLANT LICENSE -KIDNEY/LIVER/HEART
POLLUTION CONTROL BOARD CERTIFICATE
TRADE LICENSE CERTIFICATE
TAX & PAN Card Details
PAN Type
PAN
*
TAN
Service Tax Reg. No.
Permanent
Temporary
Corporate
Name on PAN Card
*
PAN Card Address
*
Father/Promoter Name
Date of Incorporation/ Date of Birth (dd/MM/yyyy)
Scanned File (PDF/JPG/DOC)
*
Tax Exempt - TDS%
Exempt : From Date - To Date [DD/MM/YYYY]
Tax Exempt Reason
Yes
No
-
Service Tax Reg. Validity From-To [DD/MM/YYYY]
Tax Exempt Certificate (PDF/JPG/DOC)
TAN Certificate (PDF/JPG/DOC)
Service Tax Certificate (PDF/JPG/DOC)
-
Provider Bank A/C Details
Bank
*
Bank Branch
*
Branch Code
IFSC Code
*
Account Type
*
Account No.
*
Beneficiary Name of the Account
*
Cancelled cheque(PDF/JPG/DOC)
Current
Savings
Provider DMO/Health Camp Coordinator/Functionaries/Users Details
*
Functionary Type
Functionary
Mobile
Fax
Email
SAMCOCO - SUVARNA AROGYA CAMP CO ORDINATOR
SAMCO-SUVARNA AROGYA MEDICAL CO ORDINATOR
TRANSPLANT CO ORDINATOR -TO BE FILLED FOR ORGAN TRANSPLANTS ONLY
Provider Speciality wise Infrastructure Details
Speciality
Complex secondary
Tertiary
Specialist 24x7
Emergency
Simple Secondary
Total Beds
ICU Beds
#Beds for Post-op facility
#Beds for Step-down facility
Equipment in theatres
ACCIDENT VICTIMS
ACID VICTIMS
BURNS
CAMP DOCTOR(T & L)
CARDIOLOGY
CARDIOTHORACIC SURGERY
CARDIOVASCULAR SURGERY
COCHLEAR IMPLANT
COVID
DENTAL
EMERGENCY MEDICINE
ENDOCRINE
ENDOSCOPIC
ENT
GENERAL MEDICINE
GENERAL SURGERY
GENITO URINARY SURGERY
HEART TRANSPLANT
HYSTEROSCOPIC
INTERVENTIONAL NEURORADIOLOGY
INVESTIGATIONS
KIDNEY TRANSPLANT
LIVER TRANSPLANT
MEDICAL ONCOLOGY
MENTAL DISORDERS
NEURO SURGERY
NUCLEAR MEDICINE
OBSTETRICS AND GYNAECOLOGY
OPHTHALMOLOGY
ORTHOPAEDICS
PAEDIATRIC SURGERIES
PLASTIC & RECONSTRUCTIVE SURGERY
POLYTRAUMA
PULMONOLOGY
RADIATION ONCOLOGY
RARE DISEASE
SIMPLE SECONDARY GENERAL PROCEDURES
SURGICAL GASTROENTEROLOGY
SURGICAL ONCOLOGY
General Infrastructure
Provider/Hospital Bed Strength
General Ward Beds (Total)
No. of Beds (Male)
No. of Beds (Female)
THEATRES Infrastructure
General Ward Theatres No.
ICU facility (No. of beds)
Post-op facility(No. of beds)
Step-down facility(No. of beds)
Categories wise Bed Infrastructure
Category
Available
Total Beds
#Beds for Female
#Beds for Male
Equipments
Equipment photo file with purchase order and AMC certificate/tie up document
BLOOD BANK - INHOUSE/TIE UP
BURNS AND PLASTIC SURGERY
CARDIOLOGY / CARDIOTHORASIC SURGERY
CHEMOTHERAPY
CT - INHOUSE/TIE UP
ECHO- INHOUSE/TIE UP
EMERGENCY SERVICES
HIGH FLOW OXYGEN
ICU BEDS
MRI - INHOUSE/TIE UP
NEONATAL/PEDIATRIC SURGERIES
NEUROSURGERY
ONCOLOGY
PATHOLOGY - INHOUSE/TIE UP
PHARMACY
POLYTRAUMA
RADIOTHERAPY
REGULAR FLOW OXYGEN
RENAL/UROLOGY
SURGICAL ONCOLOGY
VENTILATORS
Diagnostic facilities available: (in house)
*
Basic Diagnostic Details
*
Pathology and Biochemistry (PDF/JPG/DOC)
ECG
X-Ray/Radiology
Advanced Diagnostic Facilities Available
Details
Document (PDF/JPG/DOC)
Yes
No
If No Advanced Diagnostic, Then TieUp Facility
Distance of TieUp Facility (KM)
MoU Document (PDF/JPG/DOC)
Diagnostics/ Critical Facilities Details
Diagnostics/ Critical facilities
Available
24x7
If No, Working Hours
InHouse or OutSourced
Equipment photo file with purchase order and AMC certificate/tie up document
BIOCHEMISTRY
Yes
No
From
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InHouse
OutSourced
BONE CONDUCTION TEST - FILL ONLY FOR COCHLEAR IMPLANT
Yes
No
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InHouse
OutSourced
ECG
Yes
No
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InHouse
OutSourced
GENERAL WARD - MIN 50 BEDS
Yes
No
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InHouse
OutSourced
HAEMATOLOGY
Yes
No
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OutSourced
HLA AND DNA TYPE TESTING - FOR ORGAN TRANSPLANTS
Yes
No
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InHouse
OutSourced
IC U - MIN 3 BEDS
Yes
No
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InHouse
OutSourced
ICCU - MIN 2 BEDS - FOR ORGAN TRANSPLANTS ONLY
Yes
No
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To
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PM
InHouse
OutSourced
LAMINAR AIRFLOW OT - FILL ONLY FOR COCHLEAR IMPLANT
Yes
No
From
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InHouse
OutSourced
MICROBIOLOGY
Yes
No
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InHouse
OutSourced
MICU - MIN 2 BEDS - FOR ORGAN TRANSPLANTS ONLY
Yes
No
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InHouse
OutSourced
OT- LAMINA FLOW PATTERN
Yes
No
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InHouse
OutSourced
PAEDIATRIC INTENSIVE CARE UNIT FULLY EQUIPPED - FILL ONLY FOR COCHLEAR IMPLANT
Yes
No
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InHouse
OutSourced
PAEDIATRIC RESUSCITATION FACILITY - FILL ONLY FOR COCHLEAR IMPLANT
Yes
No
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InHouse
OutSourced
POST OP WITH VENTILATOR AND PAEDIATRIC RESUSCITATOR FACILITY - FILL ONLY FOR COCHLEAR IMPLANT
Yes
No
From
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InHouse
OutSourced
POST OPERATIVE WARD - MIN 2 BEDS
Yes
No
From
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12
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To
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PM
InHouse
OutSourced
POST-TRANSPLANT WARD/ISOLATION WARD - KIDNEY/HEART/LIVER
Yes
No
From
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To
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PM
InHouse
OutSourced
PURE TONE AUDIOMETRY - FILL ONLY FOR COCHLEAR IMPLANT
Yes
No
From
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8
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10
11
12
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30
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To
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PM
InHouse
OutSourced
SEROLOGY
Yes
No
From
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8
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12
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30
45
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To
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PM
InHouse
OutSourced
SOUND PROOF ROOMS -10’X 10’ - FILL ONLY FOR COCHLEAR IMPLANT
Yes
No
From
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7
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12
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30
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To
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PM
InHouse
OutSourced
STEP DOWN ICU WARD - MIN 2 BEDS
Yes
No
From
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11
12
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30
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To
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PM
InHouse
OutSourced
TRANSPLANT ICU - FOR ORGAN TRANSPLANTS ONLY
Yes
No
From
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InHouse
OutSourced
USG
Yes
No
From
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PM
To
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30
45
AM
PM
InHouse
OutSourced
VENTILATED 10 X 10 ROOM EXCLUSIVELY FOR AUDITORY-VERBAL THERAPY - FILL ONLY FOR COCHLEAR IMPLANT
Yes
No
From
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To
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PM
InHouse
OutSourced
X-RAY
Yes
No
From
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InHouse
OutSourced
Equipment Details
Equipment Type
#Equipments
Equipment Models
Upload File
ABR WITH FACILITY FOR CLICKS AND TONE BURSTS/ASSR - FOR COCHLEAR IMPLANT ONLY
BENAIR MICRO MOTOR - FOR COCHLEAR IMPLANT ONLY
BOYLE’S APPARATUS
CT ANGIO
DC SHOCK CONVERTOR
DIAGNOSTIC PURE TONE AUDIOMETER WITH FREE FIELD - FOR COCHLEAR IMPLANT ONLY
DIALYSIS MACHINES
DIATHERMY
ECMO
ENDOSCOPES
FACIAL NERVE MONITOR - FOR COCHLEAR IMPLANT ONLY
IMPEDANCE AUDIOMETER - FOR COCHLEAR IMPLANT ONLY
LAPAROSCOPIC EQUIPMENT
MICROEAR SURGERY INSTRUMENTS - FOR COCHLEAR IMPLANT ONLY
MONITOR
OPERATING MICROSCOPE
OPERATING MICROSCOPE WITH VIDEO RECORDING FACILITY - FOR COCHLEAR IMPLANT ONLY
OTO-ACOUSTIC EMISSION INSTRUMENT - FOR COCHLEAR IMPLANT ONLY
PULSE OXYMETER
RO PLANT - FOR ORGAN TRANSPLANTS ONLY
SKEETER/ANGLED HAND PIECE AND MICRODRILL FOR COCHLEOSTOMY - FOR COCHLEAR IMPLANT ONLY
SONOLOGY OR ULTRASONOGRAPHY
STERILITY UNIT
SUCTION APPARATUS
TELE-METRIC EQUIPMENT - FOR COCHLEAR IMPLANT ONLY
Anesthetist Details
Round the clock anesthetist facility
Anesthetist
Mobile
Email
Yes
No
Registration Number
Qualification
College/University
Years of Experience
Provider Past Performance
OP and IP Patient Cases Volume
Department
2024-2025
2023-2024
2022-2023
Out-Patients
In-Patients
Specialists Details
*
Speciality
*
Specialist Name
*
Registration No.
*
Doctor Type
*
Select Speciality
ACCIDENT VICTIMS
ACID VICTIMS
BURNS
CAMP DOCTOR(T & L)
CARDIOLOGY
CARDIOTHORACIC SURGERY
CARDIOVASCULAR SURGERY
COCHLEAR IMPLANT
COVID
DENTAL
EMERGENCY MEDICINE
ENDOCRINE
ENDOSCOPIC
ENT
GENERAL MEDICINE
GENERAL SURGERY
GENITO URINARY SURGERY
HEART TRANSPLANT
HYSTEROSCOPIC
INTERVENTIONAL NEURORADIOLOGY
INVESTIGATIONS
KIDNEY TRANSPLANT
LIVER TRANSPLANT
MEDICAL ONCOLOGY
MENTAL DISORDERS
NEURO SURGERY
NUCLEAR MEDICINE
OBSTETRICS AND GYNAECOLOGY
OPHTHALMOLOGY
ORTHOPAEDICS
PAEDIATRIC SURGERIES
PLASTIC & RECONSTRUCTIVE SURGERY
POLYTRAUMA
PULMONOLOGY
RADIATION ONCOLOGY
RARE DISEASE
SIMPLE SECONDARY GENERAL PROCEDURES
SURGICAL GASTROENTEROLOGY
SURGICAL ONCOLOGY
Select Specialist Type
Government
Private
Qualification
*
Experience Years
#Cases handled
Contract Type
Mobile Number
*
Select
MBBS
BDS
BAMS
BHMS
BUMS
BNYS
BPT
MD
MS
M.Ch
DNB
Dip
DM
FCPS
MCPS
PhD
MPT
MDS
MS(ENT)
DNB(ENT)
MASLP
M.Sc(Audiology)
M.Sc(Speech and Hearing)
MS(ORTHO)
DGO
DO
DLO
DCH
DNB(Ortho)
Others
Full-Time Permanent
Part-Time Permanent
Full-Time Contract
Part-Time Contract
Full-Time Trainee
Part-Time Trainee
On Probation
MC Certificate (PDF/JPG)
*
Healthcare Professionals Registry(HPR)
*
Other Staff Details
Department
*
Staff Name
*
Job Role
Qualification
Select Department
Accounts & Finance
Customer Relations
Customer Technical Support
General Administration
House Keeping
Human Resource & Recruitment
Investor Relations
IT Administration
Legal
Marketing & Corporate Relations
Operations
Production/Engineering
Purchase, Supply-Chain
Research & Development
Sales & Business Development
Technology Hardware Development
Technology Software Development
Press Relations
Technical Maintenance
Insurance Operations
Top Management
Medical Services
Medical Services Planning and Commissioning
Operations and Strategy
Project Coordination
Project Planning and Budget
Project Execution
Protocols and Public Relations
Systems Protocol and IT
Clinical-Obs and Gynae
Clinical-Emergency
Clinical-Neonatology
Clinical-Anesthesia
Clinical-Dermatology
Clinical-Dietetics
Nursing
Medical Technician
Facility Maintenance Services
Food and Beverage
Retail
Select
X /Secondary School
XII Standard(Higher Secondary)
B.A
B.Arch
B.B.A
B.Com
B.Ed
B.Pharma
B.Plan
B.Sc
B.E/B.Tech
BCA
BDS
BGL
BHM
BVSC
CA
CS
Diploma PG
ICWA
Integrated PG
ITI
LLB
LLM
M.A
M.Arch
M.Com
M.Ed
M.Pharma
M.Sc
M.Tech
MBA/PGDM
MBBS
MCA
MCM
MPHIL
MS
MVSC
PG Diploma
Ph.D/Doctorate
SLP/B.Ed
B.Sc (Speech & Hearing)
BED III
BSLPA
BASLP
Others
Experience Years
Contract Type
Mobile Number
*
Remarks
Full-Time Permanent
Part-Time Permanent
Full-Time Contract
Part-Time Contract
Full-Time Trainee
Part-Time Trainee
On Probation
Details of Faculty-Full time,Consultants, Duty Doctors and Para Medical Staff with Scanned Certificates (DOC/PDF)
Future Expansion Plans
Authorized Applicant Information
*
Department
*
Applicant Name
*
Job Role
Email ID
*
Select Department
Accounts & Finance
Customer Relations
Customer Technical Support
General Administration
House Keeping
Human Resource & Recruitment
Investor Relations
IT Administration
Legal
Marketing & Corporate Relations
Operations
Production/Engineering
Purchase, Supply-Chain
Research & Development
Sales & Business Development
Technology Hardware Development
Technology Software Development
Press Relations
Technical Maintenance
Insurance Operations
Top Management
Medical Services
Medical Services Planning and Commissioning
Operations and Strategy
Project Coordination
Project Planning and Budget
Project Execution
Protocols and Public Relations
Systems Protocol and IT
Clinical-Obs and Gynae
Clinical-Emergency
Clinical-Neonatology
Clinical-Anesthesia
Clinical-Dermatology
Clinical-Dietetics
Nursing
Medical Technician
Facility Maintenance Services
Food and Beverage
Retail
Telephone Number
*
Fax Number
Mobile Number
*
PreView and Print Application Form and Package Rates
Documents
Uploaded Files(PDF/DOC/XLS/XLSX/JPG)
*
Remarks
Signed and Sealed Application Form
Signed and Sealed Package Rate List
Remarks
*
DECLARATION:
We hereby accept the Ayushman Bharat- Arogya Karnataka scheme and agree to the Package Rates indicated in the Annexure 7A,7B,8&9 to GO:HFW/69/CGE/2018 dated 15.11.2018
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