1. Hospital Basic Information
Hospital Type* Hospital Name*
Hospital Parent Type *   Door Number*
Street * State*
District * Mandal/Muncipality Name*
Village* Nearest Town/City Name*
Hospital Year of Establishment* Total Bed Strength*
MD/CEO/COO/Superindent Name * Hospital PAN*  
MD/CEO/COO Contact Number * MD/CEO/COO Email ID*
Land Line Number *
2. Hospital Mandatory Approval Details
Name of approval Date of issue Date of expiry Attachments Name of approval Date of issue Date of expiry Attachments
Pharmacy licence *   Pollution control board certificate *  
Bio medical waste management certificate *   Reg certificate of Ambulance *  
Registration Certificate from DM and HO for Diagnostic Tie-up *  
3. Financial Details
Constitution of the hospital (Public/Private/Proprietary/Partnership)* Name of the authorized signatory to the hospital bank account*
Name of the Bank Account of Hospital* Hospital Bank Account number*
IFSC code* Cancel Cheque*  
Bank Name* Branch Name*
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