Name of Hospital * :
Address (line one)* :
Address (line two)* :
Address (line three)*:
State * : Select State ALL ANDAMAN & NICOBAR ISLANDS AUSTRALIA Andaman and Nicobar Andhra Pradesh Arunachal Pradesh Assam BELGIUM BULANDESHAR Bihar CHINA Chandigarh Chhattisgarh DADRA AND NAGAR HAVELI DAMAN & DIU Delhi Dhaka EGYPT ETHIOPIA FRANCE GADHCHIROLI GERMANY Goa Gujarat Haryana Himachal Pradesh IRAQ Italy JAMMU AND KASHMIR JAPAN JORDAN Jharkhand KAZAKHSTAN KOOTHATTUKULAM Karnataka Kerala LATIVA LIBYA Lakshdweep MACAU MALAWI MALAYSIA MALDIVES MAURITIUS Madhya Pradesh Maharashtra Manipur Meghalaya Mizoram Nagaland Nepal New Delhi Orissa PORT LOUIS PORTUGAL Pondicherry Puducherry Punjab REPUBLIC OF MACEDONIA REPUBLIC OF YEMEN REST OF INDIA ROMANIA RUSSIA Rajasthan SAUDI ARABIA SIKKIM SOUTH AFRICA SPAIN SWEDEN SWITZERLAND SYRIA TANZANIA TRIPURA Tamil Nadu Telangana UKRAINE UNITED KINGDOM UNITED STATES OF AMERICA UZBEKISTAN Union Territory Uttar Pradesh Uttarakhand Uttaranchal Uttarpradesh WEST INDIES WESTBENGAL West Bengal
City * : Select City
Area / Location * :
Pin Code * :
Email ID * :
Pan Number * :
Pan Name * :
Hospital Registration * :
Validity :
Service Tax No :
STD Code * :
Landline Number * :
Fax No:
TPA Timing Mon-Sat*: 1:00 2:00 3:00 4:00 5:00 6:00 7:00 8:00 9:00 10:00 11:00 12:00 Select AM PM To 1:00 2:00 3:00 4:00 5:00 6:00 7:00 8:00 9:00 10:00 11:00 12:00 Select AM PM
TPA Timing Sun*: 1:00 2:00 3:00 4:00 5:00 6:00 7:00 8:00 9:00 10:00 11:00 12:00 Select AM PM To 1:00 2:00 3:00 4:00 5:00 6:00 7:00 8:00 9:00 10:00 11:00 12:00 Select AM PM
Geographical Details : Latitude * Longitude *
General Information *: Select Metro City Non Metro (State Capital) Non Metro (Non State capital Population > 10 Lakhs) Non Metro (Population - 5-10 Lakhs) Non Metro (Population < 5 Lakhs) VO Location
Age of the building*: Select Less than 5 years 5 - 10 years More than 10 years
Circulation Area * :
Floor height * :
Total Area(Sq Ft): Total Built up area * IPD (Approx) * Attendants waiting area*
Premises *: Select Fully Owned premises Leased Premises Floor in commercial/residential complex
Ownership *: Select Private - Proprietorship, Partnership, Corporate Trust Missionary Government Charitable/Not for profit
Type of Speciality *: Select Day Care Centre Single Speciality Multispeciality Superspeciality Medical College Hospital
NABH Accredition Status Select Entry Level Progressive Level Accredited
JCI/Any other equivalent :
Any other Certification :
Other Empanelments: Part of GIPSA Network * Select Y N Under Government Schemes :*
Depanelment: Depanelled/Blacklisted by any Insurer/TPA/Government body * Check(If Yes)
Depenelment of Date :
IT Infra :
Hospital Information Management System :
If outsourced (Please mention the name of the vendor) *
Billing*: Select HIMS Computer Manual
Diagnosis Coding*: Select ICD10 CPT Others
MRD*: Select Digitized Physical
Feasibility of HIMS sync with Claims Application (FT) :
TPA Department :
Working Hours :
If discharge can be processed during non-working hours?
Billing Cycle : Select 24 Hrs Check out time
Others(Pls specify) :
Charges :
Deposit
Surcharges (Pls specify billing heads)
Luxury Tax
Other(Please specify) :
Billing Format :
Is Discount Term incorporated in the HMIS?
Is the final discharge invoice generated with or without agreed discount?
Discharge Summary:
Is ICD code captured?
Is CPT Code captured?
Payment Option:
Digital
EMP/Finance *: Select EMI Finance
Others (Please specify) :
Bed Distance :
Distance b/w two beds (GW) : Select < 2.5 Mts (Min.) >= 2.5 Mts
Distance b/w two beds (ICU) : Select < 2.5 Mts (Min.) >= 2.5 Mts
Total Bed Capacity *: Select Day Care<10 11 - 50 51 - 100 101 - 250 251 - 500 >500
Hospital Website * :
Hospital Profile (Brief about themselves) * : Maxmium 500 words
Hospital Photograph Select Document Type Main Building ICU/NICU/MICU OT Wards Lab
Rohini ID *
Account No * : Type of Account * : Saving Current
IFSC Code * : Bank Name * :
Cancel Cheque Copy * Select Document Type PAN Copy Cancelled Cheque
Mobile Name Email ID
TPA Co-Ordinator * :
Billing Person :
Medi. Superintendent:
Medical Director * :
Administrator :
CEO * :
Marketing Head * :
Medical Specialities (Service Available) (Yes) (No)
Cardiology :
Dermatology :
General Medicine :
Gastroenterology :
Nephrology :
Neurology :
Oncology (Chemotherapy) :
Paediatrics :
Psychiatry :
Pulmonology :
Community Health :
Palliative Medicine :
Geriatric Care :
Family Medicine :
Others :
Interventional Specialities (Yes) (No)
Oncology :
Radiology :
Vascular Surgery :
Others (Pls specify) :
Surgical Specialities(Check if Yes) Services Available(Y/N)
Cardio-Thoracic :
ENT :
General Surgery :
Neurosurgery :
Obstetric & Gynaecology :
Opthalmology :
Orthopedics :
Paediatrics Surgery :
Plastic Surgery :
Urology :
Others (Pls Specify) :
Emergency Services (Check if Yes)
Emergency Room :
Minor OT :
Burns Unit :
Trauma Centre :
ER maintained by MBBS Doctors :
Supportive Services (Yes) (No)
Radiography :
Clinical Pathology :
Cytology :
Histopathology :
Ventilator :
Endoscopy :
Hematology :
Stress Test (TMT) :
Chemist in house :
Blood fractional facility:
Chest X-Ray :
Pet Scan :
Pathology Laboratory:
Audiometry :
Laboratory/Pathology Services :
In-house (Within the premises & Owned by the provider) :
In-house (Within the premises & out sourced*):
Is Lab billed on credit for insurance patients?
No of Consultants (Pathology/Microbiology-attach list) :
List of equipment (Make/Model) & Services available (Laboratory) :
Blood Bank (License No) :
Blood Bank - Yes* (In-house) / Not Available :
License No :
License expiry date :
Blood Bank should follow NACO guidelines, drug & cosmetic act :
Radiology Services* (AERB License No) : (Yes) (No)
X-Ray (AREB Guide Lines):
2D Echo/Colour Doppler:
Mammography :
Bone Densitometry :
CT Scan :
MRI/PET Scan :
U.S.G. :
List of equipment (Make/Model) (Radiology) :
Pharmacy :
In-House 24 Hrs Pharmacy :
Is pharmacy billed on credit for insurance patients?
No of AC Beds No of NON AC Beds Rent Per Day(Inc Nursuing Charges)
AC ROOM NON-AC ROOM
ICU/ICCU/MICU/SICU/Neuro ICU :
Economy/General Ward:
Multiple Sharing :
Double Sharing :
Semi/Private :
Private/Single :
Delux :
Super Delux Beds :
Suite Beds :
Day care :
Labor Room :
HDU :
Dialysis beds :
Step Down ICU :
PICU/Neonatal ICU :
Nursery :
Bed Strength (AC and NON AC) :
Total Bed Strength :
Total ICU Beds : Others(Pls Specify) * :
Nurse to Patient (Bed) Ratio :
Nurse Bed Ratio :
Nurse-patient ratio for Emergency/Casualty :
Nurse Bed Ratio In ICU :
Doctor to Patient Ratio :
Doctor Bed Ratio :
Doctor Bed Ratio In ICU :
Operation Theaters :
Major(NOS) * : Minor(NOS) * : Labour Room * :
Specialized OT's * : Cardiothoracic * : Cathlab * :
Orthopedics * : Neurosurgery * : Transplant * :
Others (Pls specify) * :
OT Rooms :
Preparation, Pre & Post-Operative, Scrub :
Laminar Flow :
HEPA filters installed in OT's :
OT Technician * : OT Nurse (Staffing per table) * :
Anaesthetist
Full Time * : On Call * :
List of equipment and Facilities in OT
Staff :
Total Doctors :
Availability of Full Time Consultants (Append List) * :
Visiting Consultants (Append List) * :
Visiting Surgeons or Interventionists (Like cardiologists, Gastroenterologist etc.) (Append List)
Total Staff Strength : RMO : Total Doctors available for ICU :
Duty Medical Officers : P.G qualified doctors available for ICU :
MBBS doctors for ICU taking all the shifts together : Total Nursing Staff (Qualified) :
Nursing Staff (Qual) for ICU taking all the shifts together :
Paramedical Staff (Qualified) : Technicians (Qualified) :
Equipment :
List of equipment and Facilities in ICU
List of equipment and Facilities in Labour room
Any Other facility
Ambience :
Whether fully air-conditioned :
Ambulance :
Advanced Life Support (ALS) :
Basic Life Support (BLS) :
NA/Out Sourced :
Dietary Services :
In-house with qualified dietician*: Select In-house with qualified dietician Not Available
Services Not Available :
Linen & Laundry Services :
In house :
Out sourced :
Biomedical Gases :
Biomedical Gases : Select Local/Portable Cylinders Piped Gases - Localized to specific department Piped Gases- Entire Hospital
Infection Control :
Infection Control : Select Infection Control Committee Periodical checks for pest management Periodical monitoring and audits for Hospital acquired infections
CSSD :
Method of sterilizations : Select Autoclave ETO Plasma
Demarcated Area : Select Demarcated Area for Receiving Packing Cleaning Sterilization and Storage
QC for Sterilization : Select Chemical Biological Indicators
Patient safety :
Earthquake safety - Building parameters :
Fire safety drills :
Owned (In-House)
General :
Cardic :
Total :
Hospital Tariff(Schedule of charges)
Total number of patients admitted during calendar year
Total number of surgeries performed
Bed Occupancy rate (Overall & for each room)
Average LoS : Caesarean Rate :
Readmission : Referrals :
Maternal mortality rate : Neonatal mortality rate :
Net death rate : Medication Errors :
Transfusion Reaction : Average Admission Time :
Average Discharge Time : Average Length of Stay (ALOS) for Medical Cases :
Average Length of Stay (ALOS) for Surgical Cases :
Bio-Medical Waste Management : Select Segregation at Source & Disposal using Local Municipal Facilities Segregation at Source & Disposal Systems Inhouse (Incinerators,etc) No Specific Method Followed
Pollution Control Certificate :
Fire NOC :
PNDT :
MTP :
NDPS License :
Organ Transplant (Pls specify type of organ tx permitted) :
Explosive License for O2 Tank etc :
Lift Commission Certificate :
Building Plan authorized by the Civic Body :
AERB (Atomic Energy Regulatory Board) Certificate :
Name : Insurance /TPA :
From : Upto :
Terms :
General Cleanliness : Housekeepiing :
Parking Space : Waiting Rooms :
Cafeteria : Patient information System :
PMT Remark if any :
Customer Feedback:
Digital/Physical :
Access to the feedback of IL customers :
We hereby agree that ICICI Lombard can publish the above mentioned information in health advisor web site. * Yes No
