Cost : ` 1/-

FORM - I [See Rule - 4(a)] APPLICATION FOR REGISTRATION OF ANDHRA PRADESH ALLOPATHIC PRIVATE MEDICAL CARE EXTABLISHMENT
(To be submitted in Duplicate)

1.

Name & Address of the Allopathic Private Medical Care Establishment Name of Correspondent or any Authorised person for correspondence Name and address of the Society / Trust & date on which it was established Whether the accommodation is owned by the establishment or on lease / rent. If so please furnish the period of lease / rent along with the documentary proof. The date of establishment of Medical Care Establishment. Total Area of establishment (One set of photographs of the premises with its functional areas to be furnished) Bed Strength Types of Services offered

2.

3.

4.

5.

a) Open Area

b) Constructed Area

6.

7. 8.

: : a) Basic c) Super Speciality b) Speciality d) Diagnostics

9.

Names of Doctors along with registration number : allotted by MCI /APMC (Please enclose the details) :

10. Names of qualified Nursing Staff, with their Registration numbers of NCI/any other board. (Please enclose the details) 11. Names of Para Medical Staff & their Registration Numbers (List to be enclosed)

12. No. of supporting Staff (list to be enclosed) 13. No. of Specialists available. (Please enclose the details) 14. The List of Equipment and Furnisture available. (Please enclose the details) 15. Labour room with Pediatric care facilities. 16. Operation Theatres 17. Diagnostic Facilities including Clinical Laboratory and Imaging facilities. 18. Whether Registration is sought for main facility or branches also, if so details (Separate application shall be submitted for each branch) 19. The Financial position of the Hospital/ Institute (enclose audit report of the last two years) 20. Any other information relating to Hospital 21. Declaration on Stamp paper for willingness to comply with the prescribed rules is enclosed. 22. Particulars of the Registration fee paid (D.D No., Name of the Bank and Date & Amount)

: :

: : :

: : Yes /No

I here declare that the information furnished above is true to the best of my knowledge and belief and if it is found that any wrong information is furnished or suppressed the material facts, I will take full responsibility for the consequential action as per law.

(Signature) (Name and Designation and full address with official Seal) Date: Place:

1.

DISPLAY OF RATES : a) The Establishment shall display the rates charged for each type of services provided by them for the benefit of the patients at the reception counter in both the local and English language. The list of minimum services for which rates are to be displayed are given in
Name of Service Room Charges: (Includes Room / Bed Charges, Nursing Charges Medical Utilities Charges) Intensive Care Units: (Charges includes the ICU Bed Charges, Medical Utilities, Monitoring and Nursing Charges) Type of Service General Ward Private Rooms: Semi Deluxe - Shared Deluxe with A/c. MICU & ICU NEURO POW Neonatal ICU Pediatric ICU General Ward Twin / Triple Sharing General Ward Twin / Triple Sharing Hour 1 Hour General Surgical Procedures Obstetric & Gynecology Procedures Orthopedic Surgical Procedures Cardiac Surgical Procedure Other Super Speciality improved procedures Per Visit Per Visit 3 Shifts per day Charges (in Rs.)

OT Charges General Anesthesia hour General Anesthesia 1 hours Local Anesthesia Surgical Procedure Charges (Package) : (Includes Surgeons Charges + Anesthetist Charges + Nursing Home Charges and inpatient medicines Charges) Doctors consultation Charges: OP IP Emergency Visits Emergency Care Team Charges Diagnostic Charges Common Diagnostic Tests X-ray per film Ultra Sound, General and Obstetric Care

Abdomen Female Pelvic KUB Brain Plain Chest / Abdomen / Neck / Spine / Others Contract Brain Plain Chest / Abdomen / Neck / Spine Others Contrast

CT Scan: Multi Slice / Spiral / CT Scan MRI 0.5 / 1 / 1.5 (Magnetic Resonance Imaging) ECG / TMT / ECHO / EMG / EEG Upper GI Endoscopy / Lower GI Endoscopy Lab Investigations:

Random Blood Sugar Blood Urea Serum Creatinine CBP / ESR / CUE Blood Group Blood for MP LFT Lipid Profile HBSAG / VDRL / HIV Electrolytes T3, T4, TSH Note: Other Service Charges for Inpatients such as Drugs & Disposables, investigations and concessions, if any shall be displayed at appropriate place for the benefit of the patient. b) A copy of such list shall be sent to the Registration Authority by 1st June every year for record. c) The Details of services and rates shall be explained to the patients or their attendants at the time of admission without ambiguity

SERVICES OFFERED
Sl. No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Service Extract of Adangal / Pahani Extract of ROR 1B Copy of FMB Copy of Village Map F-Line Petitions Sub-Division of Lands Mutation of Entries in Revenue Records Income Certificate Residence Certificate Integrated Certificate (Caste-Nativity-Date of Birth) OBC Caste Certificate EBC Certificate Agricultural Income Certificate No Earning Member Certificate Family Member Certificate (Social Security Schemes & Govt. Employees / Pensioners) Issue of Encumbrance Certificate Certified Copy of Registration Document Money Lending License Allopathic Medical Care Registration Apathbandhu Scheme NFBS Application No Objection Certificate (Lands) Pawn Broker License School Registration Birth Certificate - GHMC Death Certificate - GHMC Birth Certificate Corrections - GHMC Death Certificate Corrections - GHMC Service Level 15 Minutes * 15 Minutes * 15 Minutes * 5 Days 30 Days 30 Days 45 Days 1st time - 7 days 2nd time & thereafter - 15 minutes 1st time - 7 days 2nd time & thereafter - 15 minutes 1st time - 30 days 2nd time & thereafter - 15 minutes 1st time - 30 days 2nd time & thereafter - 15 minutes 1st time - 7 days 2nd time & thereafter - 15 minutes 1st time - 7 days 2nd time & thereafter - 15 minutes 1st time - 7 days 2nd time & thereafter - 15 minutes 1st time - 7 days 2nd time & thereafter - 15 minutes Same day, if submitted by 2 pm 15 minutes Fresh - 45 days Renewal - 30 days 90 Days 10 Days 1 Week 30 Days Fresh - 45 days Renewal - 30 days 1 Week 15 Mins. (Category-A) 15 Mins. (Category-A) 6 Working Days 6 Working Days Service Charges (`) 25/25/25/35/35/35/35/35/35/35/35/35/35/35/35/-

16 17 18 19 20 21 22 23 24 25 26 27 28

25/25/35/35/35/35/35/35/35/25/- per transaction + statutory charges 5/- per additional copy 25/- per transaction + statutory charges 5/- per additional copy 60/- + 25/- per copy of certificate 60/- + 25/- per copy of certificate 10/- + 25/- per copy of certificate (after one year)

29 30

Child Name Inclusion - GHMC Non Availability Certificate Birth - GHMC

6 Working Days (within one year) 3 Working Days

25/- per copy of certificate 25/- per copy of certificate

NOTE : 1. Postal charges extra. 2. *Subject to availability of online digital records, otherwise the request will be processed within 7 days. 3. Printing of additional pages at ` 2/- per page.

1100

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