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 * :
Registration No * :
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 *
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 * :
No of AC Beds No of NON AC Beds Rent Per Day(Inc Nursuing Charges)
AC ROOM NON-AC ROOM
ICU /ICCU/HCU Beds :
Economy/General :
Multiple Sharing :
Tripple Sharing :
Double Sharing :
Semi/Private :
Private/Single :
Delux :
Super Delux Beds :
Suite Beds :
Total Beds :
List Of Specialities Available Medical(Y/N) Surgical(Y/N)
Medical :
General Surgery :
Cardiology :
Nephrology :
Neurology :
Gastro-Enterology :
Orthopedic :
Pulmonology :
Gyneacology :
Obsteritics :
Opthalmology :
Medical Oncology :
Urology :
ENT :
Others :
Supportive Services Yes/No (Y/N)
Radiography :
CT Scan :
MRI :
Clinical Pythology :
Cytology :
Histopathology :
Ventilator :
Endoscopy :
Hematology :
Stress Test (TMT) :
Chemist in house :
Blood fractional facility:
Chest X-Ray :
Pet Scan :
Pathology Laboratory:
Audiometry :
Full Time Consultant * : Vistiting Consultant * :
Nurses * : ICU duty/Emergency/Casualty Doctors * :
Other support staff (technicians/ housekeeping / security / etc) * :
List Of Consultants * Select Document Type In-house Doctor List Visiting Doctors List
Owned (In-House)
General :
Cardic :
Total :
24 Hrs Billing Facility :
Computerized Bills :
24 Hrs Ambulance :
24 Hrs Pharmacy :
Fax Availiability :
Hospital Tariff(Schedule of charges)
Name : Insurance /TPA :
From : Upto :
Terms :
National Accreditation Board for Hospitals & Healthcare Providers (NABH). --Select-- Pre Accreditation Progressive Level Full Accreditation
Joint Commision International (JCI) :
We hereby agree that ICICI Lombard can publish the above mentioned information in health advisor web site. * Yes No
Special Note - 1 : IT to ensure that IP address or other relevant details (Contact details of person who is submittng this form) to be captured to check & capture the genuity of the provider.
2 : Excel need to be extracted from backend for following entries.
