1. Hospital Empanelment Request Form (1).pdf

Star Health and Allied Insurance Co. Ltd Networking Dept, Corporate Office, Chennai Chennai Eail! network.hosp"starhealth.in

Hospital Empanelment Request Form Epanelent Code

Name of Hospital Registration No:

Regn. Authority

Complete Address Pincode sqft

Total Land Area Name of Owner

Super Built up area

sqft

Qualifications:

Dept

Email ID

Mobile No

TPA / Front Desk Billing / Accounts Marketing Dept Telephone Nos. Tele Fax Nos. PAN N

PAN Photocop! attached

Na%e of Bank# N"FT Details#

Branch Address

Pl. Attach $ancelled $heque

I#SC Code ! Account No!

Bank Account in the na%e of 

Specialt!

Si Single

Pl. Specif!

Multi Specialt!

&oo% $ategories &oo% Tariff No. of Beds ccupanc! '

(s the )ospital Strategicall! *ocated# +es / No

,hether )ospital has -een -lacklisted -! an! insurer if so please proide details ,hether infrastructure erification has -een carried out if so please attach details )ospital &eferred -!# Accreditations if an!. Please attach photocop! An! other infor%ation#

Super Specialt!

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Schedule of Charges agreed for Star Health and Allied Insurance Co !td

$oo Categor%

Description of Charges

Single A&C

Sharing & Single Non A&C

'eneral

&oo% &ent 0ith Nursing $harges Professional $harges per Da! Please attach separate sheets for other package rates Acceptance from Hospital

This acceptance of a-oe rates 0ill for% part of our Me%orandu% f 1nderstanding and 0ill -e alid for a %ini%u% period period of 2 !ears Na%e of the Person according acceptance Designation of Person

Signature with Date

Hospital address seal ()andator%* For "ffice #se

$roposed b%

Chec&ed b%

Signature with Designation + Date

Signature with Designation + Date

Agreed b%

onal )edical Head-s Signature + Date

onal Clais Head-s Signature + Date

Recommended for Empanelment

Sr. ) & onal )anager-s Signature + Date Recommendations of Net'or&ing Dept

Appro(ed for Empanelment

Signature with Designation + Date

Re)ected

Reasons

Signature with Designation + Date