APPLICATION FOR HOSPITAL / LAB REGISTRATION

to
all the members of IMA,

dear members,
please download or copy the following application and fill it properly and attach required documents and submit the same to the DMHO of your respective district.

FORM 1 [ FORM j
(See rule 4 (a))
APPLICATION FOR REGISTRATION OF
ANDHRA PRADESH ALLOPATHIC PRIVATE MEDICAL CARE ESTABLISHMENTS
(to be submitted in Duplicate)

1 Name & address of the Allopathic Private
Medical Care Establishment

2 Name of Correspondent or any Authorised
person.for correspondence.

3 Name and Address of the Society/Trust &
date on which it was established :

4 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.

5 The date of establishment of Medical care
establishment

6 Total area of Establishment: (One set of a)Open area b) Constructed area
Photographs of the premises with its
functional areas to be furnished)

7 Bed Strength

8 Types of Services offered (1). Basic (2) Speciality
(3) Super Speciality (4) Diagnostics.


9 Names of Doctors, along with Registration
Number Alloted by MCI / APMC


10 Names of qualified Nursing Staff, with their
of Registration numbers of NCl / any other
board
(Please enclose the details)

11 Names of Para Medical Staff &their
Registaration numbers (list to be enclosed)

12 No.of Supporting staff (list to be enclosed)

13 No.of Specialists available
(Pl.Enclose the details)

14 The List of Equipment and Furniture available
(Enclose the details)

15 Labour room with Pediatric care facilities

16 Operation theatres

17 Diagnostic Facilities including Clinical
Labaratory 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 Yes/No
comply with the prescribed rules is enclosed

22 Particulars of the Registration fee paid
(D D No., Name of the Bank, and Date).


I hereby 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 responsiblily for the consequential action as per law.

Place:
(Siganature)
Date: (Name and Designation and full address
with Otficial Seal)



The registration fee payable annually or in (1) one instalment (for entire 5 years) is as follows:
Category No.
Description of the Private Medical Care Establishment
Annual Fee
(Rs.)
1Clinics/consultation rooms (Solo Practitiner) 250

2.Poly Clinics (Group Practitioners) 500

3Hosp Nursing Homes less than 20 beds 750

4 Hospitals/ Nursing Homes with 21 to 50 beds 1500

2000
5 Hospitals! Nursing Homes with 51 to 100 beds 2000

6 Hospitals! Nursing Homes with 101 to 200 beds 3000

7 Hospitals! Nursing Homes with more than 200 beds 7500

8 Diagnostic Centers (Basic Lab facilities) 500

9 Diagnostic Centers with Hi-end equipment (CT etc.) 2000

10. Physiotherapy Units 750

11 Dental Clinics! Hospitals 750

The fee shall be paid by a demand draft drawn in favour of the Registration Authority concerned on any scheduled bank payable at the headquarters of the Registration Authority concerned.