Star Health and Allied Insurance Co.

Ltd
Networking Dept, Corporate Office, Chennai Email: network.hosp@starhealth.in

Hospital Empanelment Request Form

Empanelment Code

Name of Hospital
Registration No: Regn. Authority

Complete Address

Pincode
Total Land Area sqft Super Built up area sqft
Name of Owner Qualifications:
Dept Email ID Mobile No

TPA / Front Desk

Billing / Accounts
Marketing Dept

Telephone Nos.

Tele Fax Nos.

PAN NO PAN Photocopy attached

Name of Bank:

NEFT Details: Branch Address

Pl. Attach
Cancelled Cheque IFSC Code :
Account No:
Bank Account in
the name of
Specialty Single Pl. Specify Multi Specialty Super Specialty
Room Categories

Room Tariff

No. of Beds
Occupancy % Is the Hospital Strategically Located: Yes / No
Whether Hospital has been blacklisted by any
insurer, if so, please provide details
Whether infrastructure verification has been
carried out, if so, please attach details
Hospital Referred by:
Accreditations, if any. Please attach photocopy

Any other information:

Schedule of Charges agreed for Star Health and Allied Insurance Co. Ltd
Room Category
Description of Charges
Single A/C Sharing / Single Non A/C General
Room Rent with Nursing Charges

Professional Charges per Day

Please attach separate sheets for other package rates
Acceptance from Hospital
This acceptance of above rates will form part of our Memorandum Of Understanding and will be valid for a
minimum period of 3 years
Name of the Person
according acceptance
Designation of Person

Signature with Date Hospital address seal (Mandatory)

For Office Use

Proposed by Checked by

Signature with Designation & Date Signature with Designation & Date

Agreed by

Zonal Medical Head’s Signature & Date Zonal Claims Head’s Signature & Date
Recommended for Empanelment

Sr. ZM / Zonal Manager’s Signature & Date

Recommendations of Networking Dept.
Approved for Empanelment Rejected Reasons

Signature with Designation & Date Signature with Designation & Date

Personal and Caring