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
General Information
24Hrs. Indoor
Ver: G\N -1.0
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?
Are you registered with Income Tax Dept. for IT Exemption?
YES \ NO
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
Leased
Partnership
Corporate
Public Limited
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
Head of Operation/ admin
Accounts and Billing
Admission
Clinical Information
Interaction with Star
Medical Records
ICU
Casualty
Operation Theater/Labour Room
1
Name
Tel. No.
Ext.
Mobile No.
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
EQUIPMENT
Minor
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
EQUIPMENT
Assistant
Supporting Staff
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
Yes
No
Description
Digital X-Ray
Contrast Studies
Portable X-ray
IMAGING
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
 GeneralMedicine
 Endocrinology
 Hepatology
 Rheumatology
 ENT
 Ophthalmology
 Dermatology
 Gastroenterology
 Cardiology
 Pulmonology
 Urology
 Nephrology
 Neurology
 Psychiatry
 General Surgery
 Cardio Thoracic Surgery
 Orthopedics
 SurgicalGastroenterology
 Neuro Surgery
 Plastic Surgery
 Transplant Surgery
 Obstetrics & Gynecology
 Neonatology
 Pediatrics
 Dental
 Others (Specify)



Please indicate the equipments available in your hospital:
Cardiology
Yes
No
Description
Yes
No
Description
Yes
No
Description
Yes
No
Description
Yes
No
Description
Yes
No
Description
ECG
ECHO
TMT
Holter Monitor
Cath Lab
Nuclear Scan
ENT
Audiometer
Triple Endoscopy
Gastroenterology
OGD
Colonoscopy
ERCP
Gynecology
Labour Room
Fetal Incubator
Neonatal resuscitation kit
Fetal Monitor
Neonatal ICU
Opthalmology
Phaco
Laser
Urology
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
Telecobalt
Linac
Brachy Therapy
Others
PFT
EEG
EMG
Others
Medical Records
Yes
No
Description
Yes
No
Description
(Tick which ever is applicable)
Identification of indoor patient
Medical Records Maintained for
Medical Records Management
1
2
3
Number & Year of
Admission
By Name
<1 Year
1 to 3 Years
> 3 Years
Person
Section
Department
OTHER AMENITIES / Credits Available
S. No.
Amenities
1
Unique Identifier
Details
JCI (USA)/ ACHSI(Australia)/ TRENT (UK/Europe)/CCHSA(Canada) -
Accreditation
2
3
4
NABH
NABL
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