STAR HEALTH AND ALLIED INSURANCE CO.

Ltd
No.1, New Tank Road, Valluvarkottam High Road,
Nungambakkam, Chennai – 34. www.starhealth.in
Toll free No: 1800 425 2255 BOARD No: 044 - 28263300

Network Hospital Grading Proforma Ver: G\N -1.0

General Information 24Hrs. Indoor YES \ NO
Name of Healthcare Unit
Registration Number (If Registered)
Registering Authority
Owner / CMD’s Name & Qualification

Address

Landmark, if any (Location)

City /Taluk
District
State
Pin
Telephone(s) with STD Codes
Fax Number(s)
Mobile Phone/s
E-mail Id
Website
Other Details:
Whether your Organization is a Non Profit Organization? YES \ NO
Are you registered with Income Tax Dept. for IT Exemption? YES \ NO
PAN No.
Bank Details:
Name of Bank
Branch & Address
Account Number
Account in the Name of
IFSC Code:
Hospital Details:
Type of Ownership Proprietary Charitable Trust Private Limited Public Limited

Leased Partnership Corporate

Total Land Area ____________________ , Super Built up Area __________________(Area in Sq. Feet)
Hospital Type: Multi Specialty Single Specialty Clinic Other (specify
(Please tick the appropriate box)
If single specialty please mention the specialty:_____________ Number of Total Beds in the Hospital:

Contact Details:
Contact Person for Name Tel. No. Ext. Mobile No.
Head of Operation/ admin
Accounts and Billing
Admission
Clinical Information
Interaction with Star
Medical Records
ICU
Casualty
Operation Theater/Labour Room

1 Date:
Form Confidential Signature & Seal
 STAR HEALTH AND ALLIED INSURANCE CO. Ltd
No.1, New Tank Road, Valluvarkottam High Road,
Nungambakkam, Chennai – 34. www.starhealth.in
Toll free No: 1800 425 2255 BOARD No: 044 - 28263300

OT – COMPLEX:

Number of OT: Major Minor

EQUIPMENT DESCRIPTION WITH DATE OF MANUFACTURE

Laminar Air Flow (Yes \ No)

Hepa Filter (Yes \ No)

Vinyl Floor
Type of OT Table/Ortho
attachment

Light LED / Halogen / Tube-light

Multiparameter Monitor With

Capnography
C-Arm – Specification

Laparoscopy Unit ( Brand &

Specification)
Boyle’s Apparatus / Defibrillator

Operating Microscopy / Diathermy

Radiant Warmer

Autoclave

Others

2 Date:
Form Confidential Signature & Seal
 STAR HEALTH AND ALLIED INSURANCE CO. Ltd
No.1, New Tank Road, Valluvarkottam High Road,
Nungambakkam, Chennai – 34. www.starhealth.in
Toll free No: 1800 425 2255 BOARD No: 044 - 28263300

ICU \ IMCU :

Man power: Doctors Staff Nurse Assistant Supporting Staff

EQUIPMENT DESCRIPTION WITH DATE OF

MANUFACTURE
Central Oxygen / Suction

Number of Ventilators with details

Monitor

Pulse oxymeter

Others

Details of Beds

Type of Bed No. of Beds No. of Toilets Staff

General Ward – Male

General Ward – Female

A.C./Deluxe/Suite
Single Bed

Sharing

ICU \ IMCU
Post Operative Ward

Day Care
Dialysis

Burns Unit

3 Date:
Form Confidential Signature & Seal
 STAR HEALTH AND ALLIED INSURANCE CO. Ltd
No.1, New Tank Road, Valluvarkottam High Road,
Nungambakkam, Chennai – 34. www.starhealth.in
Toll free No: 1800 425 2255 BOARD No: 044 - 28263300

Diagnostic Services
Lab Services Yes No Description
Hematology

Biochemistry

Microbiology

Serology

Histopathology

Biomedical Department

RADIOLOGY Yes No Description

Digital X-Ray

Contrast Studies

Portable X-ray

IMAGING Yes No Description

Ultra Sound

Mammogram

Color Doppler / Duplex

Scan
CT- Scan

MRI

PET Scan

4 Date:
Form Confidential Signature & Seal
 STAR HEALTH AND ALLIED INSURANCE CO. Ltd
No.1, New Tank Road, Valluvarkottam High Road,
Nungambakkam, Chennai – 34. www.starhealth.in
Toll free No: 1800 425 2255 BOARD No: 044 - 28263300

Multi specialty Hospital - please indicate the specialties available in your hospital: (Please tick the appropriate box)

Anesthesia
Oncology
General Surgery
Neonatology

GeneralMedicine
Endocrinology
Cardio Thoracic Surgery
Pediatrics

Cardiology
Hepatology
Orthopedics
Dental

Pulmonology
Rheumatology
SurgicalGastroenterology
Others (Specify)

Urology
ENT
Neuro Surgery
_________________

Nephrology
Ophthalmology
Plastic Surgery
_________________

Neurology
Dermatology
Transplant Surgery
_________________

Psychiatry
Gastroenterology
Obstetrics & Gynecology

Please indicate the equipments available in your hospital:

Cardiology Yes No Description

ECG
ECHO
TMT

Holter Monitor
Cath Lab
Nuclear Scan

ENT Yes No Description

Audiometer
Triple Endoscopy

Gastroenterology Yes No Description

OGD

Colonoscopy
ERCP

Gynecology Yes No Description

Labour Room

Fetal Incubator
Neonatal resuscitation kit
Fetal Monitor
Neonatal ICU

Opthalmology Yes No Description

Phaco

Laser

Urology Yes No Description

5 Date:
Form Confidential Signature & Seal
 STAR HEALTH AND ALLIED INSURANCE CO. Ltd
No.1, New Tank Road, Valluvarkottam High Road,
Nungambakkam, Chennai – 34. www.starhealth.in
Toll free No: 1800 425 2255 BOARD No: 044 - 28263300
ESWL
URS
PCNL
Cystoscope
Radiation Oncology Yes No Description
Telecobalt
Linac
Brachy Therapy

Others Yes No Description

PFT
EEG
EMG
Others

Medical Records (Tick which ever is applicable)

Number & Year of
1 Identification of indoor patient By Name Admission Unique Identifier
2 Medical Records Maintained for <1 Year 1 to 3 Years > 3 Years
3 Medical Records Management Person Section Department
4 Medical Records Kept Hospital Premises Outside Premises

OTHER AMENITIES / Credits Available

S. No. Amenities Details
JCI (USA)/ ACHSI(Australia)/ TRENT (UK/Europe)/CCHSA(Canada) -
1
Accreditation
2 NABH
3 NABL
4 Recognition for DNB
5 CSSD
6 ICD Coding / MRD
7 Medical Audit
8 Blood Bank
9 Fire Safety Mechanism
10 Ambulance
11 In house 24 Hrs Pharmacy
12 Computerized Billing with CGHS Available Billing
13 IT Solutions (Software License)
14 Backup Generator
15 Pantry
16 Others
(Any services existent in your organization but not mentioned above can be added in the blank spaces. Attach more sheets if
required.)

6 Date:
Form Confidential Signature & Seal