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NHB Renewal Application 2022

This document is an application for renewal of enrollment with the Indian Medical Association - Tamil Nadu State Branch Nursing Home and Hospital Board. It requests general information about the applicant such as name, address, contact details, type of ownership, facilities and services provided. The applicant declares that they will abide by the Board's guidelines. It provides instructions on payment of renewal fees via demand draft and submitting the completed application to the Secretary of the Board.

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Chandran Ochathevar
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83 views4 pages

NHB Renewal Application 2022

This document is an application for renewal of enrollment with the Indian Medical Association - Tamil Nadu State Branch Nursing Home and Hospital Board. It requests general information about the applicant such as name, address, contact details, type of ownership, facilities and services provided. The applicant declares that they will abide by the Board's guidelines. It provides instructions on payment of renewal fees via demand draft and submitting the completed application to the Secretary of the Board.

Uploaded by

Chandran Ochathevar
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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INDIAN MEDICAL ASSOCIATION – TAMILNADU STATE BRANCH

NURSING HOME AND HOSPITAL BOARD

APPLICATION FOR RENEWAL


(To be filled in BLOCK LETTERS only)

I GENERAL INFORMATION
Name of Health Care Unit :

24 Hrs. : Y N
Address :

City / Taluk :
District :
PIN :

Mobile Phone(s) :
Email Id :
Website :

Hospital Details
Types of ownership : Proprietary / Partnership/ Pvt. Ltd./ Charitable Trust
Hospital Type : Multi Speciality / Single Speciality

If single specialty please mentions the speciality : ________________

II DETAILS OF BEDS – ROOM STATUS


Type of Bed No. of Beds
General Ward - Male
General Ward - Female
Single Bed
Twin Sharing
A.C. / Deluxe / Suite
Day Care
Total

III DETAILS OF BEDS – OXYGEN STATUS


Type of Bed No. of Beds
ICU- BEDS
OXYGEN - BEDS
NON-OXYGEN - BEDS
Total

Page1
IV. FACILITIE STATUS
Emergency & Casualty YES NO
Intensive Care Unit: YES NO
Operation Theatre YES NO
CSSD/Sterilizations YES NO
Laboratory YES NO
Pharmacy YES NO
Kitchen /Mess YES NO
Bio-Medical Waste Dept. YES NO

V. IMMAGING SERVICES STATUS


X-Ray YES NO
Portable X-Ray YES NO
Ultrasound YES NO
Mammogram YES NO
CT- SCAN YES NO
MRI YES NO
PET Scan YES NO
Nuclear Scan YES NO

VII. NO. OF STAFFS


Doctors
Nurses
Pharmacist
Technicians
Housekeeping workers
Admin Staffs

Representing Doctor's Designation :

Representing Doctor's Name** :

IMA Life Member Number* :

IMA Branch in which the Representing:

Page2
DECLARATION

I hereby declare that my / our establishment will abide by the guidelines given by the
Private Hospitals and Nursing Homes Board of IMA now and then, which is a basic
qualification for enrollment/renewal in the Board.

I am also aware that the decisions of the State Council of IMA Tamilnadu State Branch
are final with regard to any matter concerned with the Private Hospitals and Nursing Homes
Board of IMA Tamil Nadu.

HOSPITAL SEAL (SIGNATURE OF THE REPRESENTING DOCTOR)

*To be filled in by the IMA Branch in which representing Doctor is a Life Member.

The above statements (with special reference to item No ……….) made by the applicant have
been verified to be true and is being recommended for enrolment in the Private Hospital and Nursing
Home Board of IMA

SEAL Signature of the President/Secretary/


of the Branch Concerned

DETAILS REGARDING RENEWAL FEE:

The renewal fee will have to be paid by Demand Draft drawn in favour of “IMA NHB GENERAL
FUND” for Rs.3,000/- and “IMA NHB JOURNAL FUND” for Rs. 2,000/- payable at Tirunelveli.

TOTAL MEMBERSHIP FEE Rs. 5,000/-

DD No.: Date: Bank ____________________ Rs.3,000/- Place

DD No.: Date: Bank ____________________ Rs.2,000/- Place

This includes renewal of Hospital / Nursing Home in the Nursing Homes Directory and
NHB Quarterly Journals.

Special contribution can be raised at the time of need as decided by the State
Council for anyspecial activities.

Page3
Send the filled up application along with DD to:

Dr. R. Anburajan
Secretary, NHB, IMA TNSB
Peace Health Centre,
48.H/5, South Bye Pass Road,
Near New Bus Stand
Tirunelveli – 627005
Ph : 0462 – 2909889
( During hours : 9.30am to 6.30pm )
Cell : 7548825544, 8778484015, 9442612138
Email : imanhbtnsb@gmail.com
Website : www.imanhb.org

For Office Use:

Received On : Receipt No. :

Enrollment No. : JM D.O.J :

Valid up to :

Certificate Sent on: By Post / Courier No.

Authorisation Signature of IMA NHB

Page4

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