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[See rule 4 (a)]
Application for Registration of Telangana Allopathic Private Medical Care Establishments
(to be submitted in Duplicate)
  1. Name and 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 and 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. (Please Enclose the relevant copies)

  5. The date of establishment of Medical care establishment

  6. Total area of Establishment: (One set of photographs of the premises with its functional areas to be furnished)

    1. Open area
    2. Constructed area
  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 Allotted by MCI/APMC (Please Enclose the details)

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

  11. Names of Para Medical Staff and their Registration numbers (list to be enclosed)

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

  13. No. of Specialities available (Please Enclose the details)

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

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

  16. Labour room with Paediatric care facilities

  17. Operation theatres

  18. Diagnostic Facilities including Clinical Laboratory and Imaging facilities

  19. Whether registration is sought for main facility, or branches also, if so details (separate application shall be submitted for each branch)

  20. The financial position of the Hospital/Institute (enclose Audit Report of the last two years)

  21. Any other information relating to Hospital

  22. Declaration on Stamp Paper for willingness to comply Yes/No with the prescribed rules is enclosed

  23. Particulars of the Registration fee paid (D.D No., Name f 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 arterial facts, I will take full responsibility for the consequential action as per law.