Central Government Health Scheme cghs



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Central Government Health Scheme (CGHS)


Application form (CGHS-03)

for Empanelment of Dental Clinics





National Accreditation Board or Hospitals & Healthcare Providers (NABH)

Quality Council of India
5th Floor, ITPI Building, 4 A, Ring Road, IP Estate
New Delhi - 110 002
Ph.: +91 11 23323416, 23323417, 23323418, 23323419, 23323420
Fax: +91 11 23323415
E-mail:
helpdesk@nabh.co Website: www.nabh.co

SECTION: 1
GENERAL INSTRUCTIONS AND ELIGIBILITY CRITERIA


  1. Categories of Cities. CGHS for purpose of empanelment has categorized the cities as:

Metro cities

Non-metro cities


  1. Categories of Health Care Facilities: CGHS would consider the following categories of health care facilities for empanelment :-




  1. Hospitals 1) General purpose hospitals// Multispeciality hospitals

2) Super specialty hospitals


  1. Diagnostic Centers.

(e) Eye Clinics


(f) Dental Clinics.
3. Fire safety measures in the centres/clinics should be in place.
4. Compliance to bio-medical rules shall be ensured
5. Submission of Application Forms:


  1. The applications must be submitted along with relevant application form, application fee and relevant annexure to NABH Office, New Delhi.



  1. The applicable fee is as follows:




S. No.

Type of facility

Bed Strength

Inspection Fee (Rs)

(1)

Hospitals

More than 100 beds

35,000/-

Less than 100 beds


30,000/-

(2)

Diagnostic, Eye & Dental Centres


Not applicable

25,000/-

Note: Service Tax of 14% will be charged on the above fees.


  1. The fee has to be submitted either online or through a demand draft in favour of Quality Council of India payable at New Delhi




  1. Application forms should be submitted in one sealed envelope superscribed as ‘Application for CGHS empanelment of hospital’.




  1. Only typed application forms shall be accepted.




  1. All the pages of Application and Annexures shall be serially numbered. Every page of application form and Annexures need to be signed by the competent person.




  1. The applicant shall nominate a nodal person for coordinating all activities related to empanelment purposes.


SECTION II
APPLICATION FORMAT FOR DENTAL CLINICS
PART 1

(Technical and Infrastructure Specifications of the Dental Clinics)
1. Name of the Dental Clinic:

___________________________________________________________________



2. Contact Details of the Dental Clinic:
Name of the Contact Person_________________________________________

Street Address

City/Town____________________________________________________________

Locality/Village/Tehsil__________________________________________________

District______________________________________________________________

State _____

Telephone________________________Mobile_____________________________

Email_____________________________________________________________


Website___________________________________________________________

SIGNATURE OF THE HEAD OR AUTHORIZED NOMINEE




  1. Location of Dental Clinic: Urban □ Rural □


Does the Dental Clinic have split location(s): Yes □ No
If yes, address of the other location(s) and distance from main location

____________________________________________________________________


____________________________________________________________________



  1. Ownership:




□Private – Corporate

□Armed Forces




□PSU

□Trust

□Government

□Charitable

□Others (Specifiy.........................................................................................



  1. Year and month in which registered and under which authority (as per state and central requirements)

____________________________________________________________________




  1. Year and month in which clinical functions started:

____________________________________________________________________



Remarks of QCI (NABH)

SIGNATURE OF THE HEAD OR AUTHORIZED NOMINEE
PART II: DENTAL CLINIC INFORMATIONS



Ser

No

Subject

Information given by Dental Clinic

Remarks of

QCI (NABH)




1.

Building










Total Area (Sq.mt)











Built up Area (Sq.mt)

(Constructed areas of all floors)













Reception and waiting for Relatives (Specify approx area)









PART III: STATUORY COMPLIANCE INFORMATION

(as per tender document requirement)



S

No

Subject

Information given by Dental Clinic

Remarks of

QCI (NABH)







STATUTORY COMPLIANCES (Mention “NA” whichever is not applicable)

Licence /Certificate No.

Valid from

Valid to

Status (Valid/Expired

(if expired details of renewal application








Fire NOC



















AERB Licenses/approvals/registrations for Radiology Equipments (as per the scope)



















PNDT



















Blood Bank license



















MTP



















Pollution Control Licenses (Air, Water and Bio-Medical Waste)



















Narcotic Drugs and Psychotropic Substances (NDPS) license




















Organ Transplant (specify separately type of organ transplant permitted)



















Explosives license for O2 tank etc



















(Note: Attach relevant documents/certificates for all the above)

SIGNATURE OF THE HEAD OR AUTHORIZED NOMINEE



PART III: FACILITIES APPLIED FOR
1. Applied for Empanelment as
General Dentistry

Specialized Dentistry

Diagnostic procedures/investigations for Dental

2. Dental Care Centre (Infrastructure and technical specifications).


(a) (i) For General Dental Clinic
(Availability of recovery bed for Dental Clinic) Yes No

(if available, specify the number of beds)

(ii) For Specialized Dental Clinic
(Whether beds are available for Specialized Yes No

Dental Clinic)If, yes Number

(b) Whether separate O.T available for aseptic/septic cases

(for Specialized Dental Clinics) Yes No


(c) Alternative Power supply Yes No


(d) (i)Laboratory facilities for routine Clinical Pathology,

Biochemistry, Microbiology …………. Yes No

(ii)Routine facilities for X-ray OPG Dental X-ray Yes Yes No


(e) No. of visiting Specialists

(For Dental Care Centre)

(Name and Qualifications of the following Specialty)
(i)Oral & Maxillo facial Surgeon

(ii)Periodontist

(iii)Prosthodontist

(iv)Endodontist


(v)Orthodontist

(vi)Paedodontist

(f) Dental X-ray Machine


IOPA 60-70 Kv, 8MA, Exposure Yes No

(with minimum radiation leakage) time selection 0.01 to 3 seconds

O.P.G. Machine 60-70 Kv8 MA Yes No

* All Specialists employed on regular and visiting basis must possess Dental Council of India’s recognized qualifications. A Post Graduate should head each speciality.


Remarks of QCI (NABH)



Declaration: I hereby declare that the details furnished above are true and correct to the best of my knowledge and belief and I undertake to inform you of any changes therein, immediately.
SIGNATURE OF THE HEAD OR AUTHORIZED NOMINEE

Name:


Date:

Annexure 1

The compliance of the following will be assessed through observations,interviews and/or documentary evidences



S.No

Particular

To be filled by HCO

Remarks of QCI/NABH




a.

Process of registration of patients

YES/NO





b.

Initial assessment patient being done as required

YES/NO





c.

Display of signage

YES/NO





d.

Scope of services displayed

YES/NO





e.

Procedure for infection control practices exists

YES/NO





f.

Display of patients’ charter (including rights & responsibilities)

YES/NO





g.

Training of the staff for the job assigned

YES/NO





h.

Medical records (manual/electronic)

YES/NO





i.

Records are being kept in safe environment and confidentiality

is being maintained



YES/NO





j.

Procedures for maintaining personal files of staff (regular/contractual

YES/NO





k.

Availability of hand hygiene/hand washing facilities

YES/NO





l.

Tariff list available

YES/NO






Remarks of QCI (NABH)

SIGNATURE OF THE HEAD OR AUTHORIZED NOMINEE



SECTION III

RECOMMENDATIONS OF QCI (NABH)

1. ……………………………………………………………………………………….. (Name of Dental Centre). is recommended/not recommended for empanelment for Central Government Health Scheme (CGHS) for the following services:.


(Note : Mention R for Recommended and NR for Not Recommended. Strike out specialities not offered for empanelment with an X)

Remarks of QCI (NABH)

(a) General Services

(b) Specialised Services
(i) Oral & Maxillo Facial Surgery
(ii) Periodontia
(iii) Prosthodontia


  1. Endodontia




  1. Orthodontia

(vi) Paedodontia




Seal of NABH SIGNATURE OF THE AUTHORIZED OFFICER

OF NABH/QCI


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