Dear Dr. / Sir / Madam, Greetings from Spurthi Meditech!

We a r e delighted in informing you that Spurthi Meditech (TPA) Solutions Pvt Ltd have been licensed by IRDA as an approved Third Party Administrator. It will be our pleasure in assisting you to empanel your esteemed institution a s o u r preferred Service Providers. Spurthi Meditech TPA Solutions Pvt Ltd has been shaped by a group of experienced professionals from the insurance and healthcare industries to bring in rich domain knowledge and deep understanding of business. The Vision of Spurthi Meditech is to emerge as a preferred player bridging the service providers and customers with supreme operational efficacy. Please find enclosed the Hospital Survey Questionnaire and kindly return the same duly filled along with your latest detailed tariff at the earliest. We will truly appreciate if you can provide the soft copy of your tariff and mail us at hospitalempanelment@spurthimeditech.com. On receipt of the documents, our medical team will review the information and will communicate the empanelment status to you. For any further information in this regard, please feel free to contact the undersigned. Spurthi Meditech looks forward for a long and mutually beneficial relationship. Thanking you, Yours Truly,

Dr. B. Ravi Kishore Chief Medical Officer Ph: 080 40111111 Mob: +91 9972099500
Regd. Office: No. 82 | Maruthi Ramakrishna Arcade | 2nd Floor | Dr. Rajkumar Road | Rajajinagar 2nd Block Bangalore-560 010. Phone: +91 80 40 111 111 | +91 80 40 505 050. Fax: +91 80 40 111 112 E-mail: hospitalempanelment@spurthimeditech.com / Web: www.spurthimeditech.com

HOSPITAL SURVEY QUESTIONNAIRE

: Aum medical nursing home

Name of the Hospital

Address

:ff, shakuntal complex, Nalanda cross road, wagodia road. Vadodara

District Sub-District Name of the Gram/Panchyat Village State Contact person's Name

: vadodara : : : :Gujarat :Dr. amit shah :9824163630 :aumhospital@yahoo.co.in

Mobile Number E-Mail ID

Regd. Office: No. 82 | Maruthi Ramakrishna Arcade | 2nd Floor | Dr. Rajkumar Road | Rajajinagar 2nd Block Bangalore-560 010. Phone: +91 80 40 111 111 | +91 80 40 505 050. Fax: +91 80 40 111 112 E-mail: hospitalempanelment@spurthimeditech.com / Web: www.spurthimeditech.com

A. Basic Information about the respondent Details of the person filling in the Questionnaire Name Age Are you in charge of this Facility Status Code Dr. Amit shah 37 1- Yes, 2- No. Remarks

A.1 a A.1 b A.1 c

A.1 Designation d A.1 Qualification e B. Characteristics of the Hospital Type of Facility B. 1 Type Status Code Public facility Private for Profit Private not for Profit Remarks

C. Empanelment / Accreditation Item Status Code Has the hospital been empanelled 1- Yes by a Health Insurance / Other 2- No Schemes If yes, by how many ( Give Details ) Public Agency Private Agency Has the hospital been accredited/ 1. Yes certified by any agency ? 2. No If yes by whom? ( Furnish Details ) Remarks

C.1 a C.1 b C.1 c

C.1 d D. Information on Staff.

How many workers work at this facility in total ( On roll Employees)?...................... (Here workers refer to Doctors, Nurses, Paramedical staff, Laboratory technicians and Pharmacist and other non-medical persons)

List Workers by name Category of Staff

Total Number

On Hospital Rolls

Contractual/ other arrangement s

Not Applicable / Service Not available

Regd. Office: No. 82 | Maruthi Ramakrishna Arcade | 2nd Floor | Dr. Rajkumar Road | Rajajinagar 2nd Block Bangalore-560 010. Phone: +91 80 40 111 111 | +91 80 40 505 050. Fax: +91 80 40 111 112 E-mail: hospitalempanelment@spurthimeditech.com / Web: www.spurthimeditech.com

D.1 D.1 a

D.1 B

Doctors and Nurses Doctors with Post 1 Graduate Qualification (MD,MS,MCh,DN B) MBBS Doctors

D.1 c D.1 d D.2 D2 a D.2 b D.2 c D.2 d D.2 e D.2 f D.3 D.3 a D.3 b D.3 c D.3 d

AYUSH Doctors Total No of Nurses (Senior and Junior) Paramedical Staff OT Pathology Lab Radiology Lab Others Pharmacists 1 8+3 3

On demand On demand

Other Medical Personnel Other Non-Medical Person Peons / Ward Boys Sweepers Security Personnel Any Other Categories 3

E. Physical Infrastructure- Current Size of the Hospital / WARDS and PRIVATE ROOMS. ITEM Size(Area) of the Hospital Remarks

E.1a

Regd. Office: No. 82 | Maruthi Ramakrishna Arcade | 2nd Floor | Dr. Rajkumar Road | Rajajinagar 2nd Block Bangalore-560 010. Phone: +91 80 40 111 111 | +91 80 40 505 050. Fax: +91 80 40 111 112 E-mail: hospitalempanelment@spurthimeditech.com / Web: www.spurthimeditech.com

E.1b

(Plot Size in Sq Meters) Number of indoor beds 22

Availa ble

Functioni Tempor ng ary / in Corridor s

E.1c

E.1.c 1 E.1.1 c.2

Total Number of Patient Toilets Male Female

E.2

Total Number of Toilets for Staff How Many Wards do you have? ( Number to be given) List the wards by Name general, Specialist by gender 2 general

E.3a

E.3b

General ward Special room Deluxe room

E.4

How Many private rooms do you have?

F. Availability of Services. Services Specialist Services Status Code Remarks

Regd. Office: No. 82 | Maruthi Ramakrishna Arcade | 2nd Floor | Dr. Rajkumar Road | Rajajinagar 2nd Block Bangalore-560 010. Phone: +91 80 40 111 111 | +91 80 40 505 050. Fax: +91 80 40 111 112 E-mail: hospitalempanelment@spurthimeditech.com / Web: www.spurthimeditech.com

F.1a F.1b F.1c F.1d F.1e

General Medicine General Surgery Obstertic & Gynaecology Paediatrics Emergency Services (24 Hours) Neonatology Anesthesia

1. 2. 1. 2. 1. 2. 1. 2. 1. 2. 1. 2. 1. 2.

Yes * No Yes No * Yes No * Yes No * Yes * No Yes No* Yes * on demand No

F.1f F.1g

F.1h F.1i F.1j F.1k F.1l

Orthopedics ENT Radiologist and Ultrasonologist Ophthalmology Dermatology and Venereal Diseases (Skin & VD )RTI / STI Dental Care AYUSH

1. 2. 1. 2. 1. 2. 1. 2. 1.

Yes No * Yes No * Yes * on demand No Yes No * Yes

2. No * 1. 2. 1. 2. Yes * on demand No YES NO *

f.1m f.1n

f.1o Others, Specify. G. Support Services.

Regd. Office: No. 82 | Maruthi Ramakrishna Arcade | 2nd Floor | Dr. Rajkumar Road | Rajajinagar 2nd Block Bangalore-560 010. Phone: +91 80 40 111 111 | +91 80 40 505 050. Fax: +91 80 40 111 112 E-mail: hospitalempanelment@spurthimeditech.com / Web: www.spurthimeditech.com

G.1

Support Services Available Finance ( Financial Accounting ) Ambulance Services

Availability? 1. Yes * 2. No 1. Yes 2. No

Outsourced? 1. Yes 2. No Outsourced 1 * In-house 2 Outsourced 1 * In-house 2 If Outsourced Written Contract-1 No Written Contract 2 If Outsourced Written Contract-1 No Written Contract - 2 If Outsourced Written Contract-1 No Written Contract 2

G.2

G.3

Dietary Services

1. Yes 2. No

G.4

Laundry Services

1. Yes 2. No

Outsourced 1 * In-house 2 Outsourced 1 * In-house 2 Outsourced 1 * In-house 2 Outsourced 1 In-house 2

If Outsourced Written Contract-1 No Written Contract 2 If Outsourced Written Contract-1 No Written Contract 2 If Outsourced Written Contract-1 No Written Contract 2 If Outsourced Written Contract-1

G.5

Security Services

1. Yes 2. No

G.6

House Keeping and Sanitation Counseling Services for Domestic violence, Gender Violence, Adolescents, Etc

1. Yes 2. No 1. Yes * 2. No

G.7

Regd. Office: No. 82 | Maruthi Ramakrishna Arcade | 2nd Floor | Dr. Rajkumar Road | Rajajinagar 2nd Block Bangalore-560 010. Phone: +91 80 40 111 111 | +91 80 40 505 050. Fax: +91 80 40 111 112 E-mail: hospitalempanelment@spurthimeditech.com / Web: www.spurthimeditech.com

No Written Contract 2

H. Hospital Processes No H.1a Process Were the financial reports for the last 2 years audited by professional Chartered Accountants? Is there a dedicated doctor for handling emergency situations 24x7 If yes, what are the qualifications of that doctor? B.Sc. Nursing /GNM is in charge of each ward? Are regular doctors rounds for all wards performed? Status 1. Yes 2. No * 1. Yes * 2. 1. 2. 1. 2. 1. 2. No Yes No Yes No Yes * No Remarks

H.1b

H.1c H.1d H.1e

MD Medicine

H.1f H.1g H.1h

Is there a mechanism for planned maintenance of equipment(Including AMCs) Are the radiologist and ultrasound machine registered under the PNDT Act? Does a female attendant accompany all female patients during investigations and consultation Are all areas of hospital swept at least twice a day? Is the OT is carbolised after each surgery? Is the Labor room carbolised after each surgery ? Is the hospital registered under

1. Yes * 2. No 1. Yes 2. No * 1. Yes* 2. No 1. 2. 1. 2. 1. 2. 1. Yes* No Yes No * Yes No * Yes *

H.1i H.1j H.1.k H.1.l

Regd. Office: No. 82 | Maruthi Ramakrishna Arcade | 2nd Floor | Dr. Rajkumar Road | Rajajinagar 2nd Block Bangalore-560 010. Phone: +91 80 40 111 111 | +91 80 40 505 050. Fax: +91 80 40 111 112 E-mail: hospitalempanelment@spurthimeditech.com / Web: www.spurthimeditech.com

H.1.m H.1.n

the BioMedical Waste Management Rules 1998? Are mortuary services available/made available whenever required? Is the blood bank providing blood registered with Drugs and Cosmetics Act ? Is there a mechanism to obtain patient feedback regularly? If yes what is the type of mechanism available Form

2. No 1. Yes * 2. No 1. Yes * 2. No

H.1.o H.1.p

1. Yes * 2. No 1. 2. Register 3. Verbal * 4. Suggestion Box *

H.1.q

Are medical records maintained for all inpatients for a period of at least 5 years

1. Yes 2. No * For the period of 3 years

I. Outpatient / In Patients Statistics I.1 Outpatient. Specialty Name Number of Outpatient cases during ( MONTH ) >1000

MD Medicine

General medicine

Regd. Office: No. 82 | Maruthi Ramakrishna Arcade | 2nd Floor | Dr. Rajkumar Road | Rajajinagar 2nd Block Bangalore-560 010. Phone: +91 80 40 111 111 | +91 80 40 505 050. Fax: +91 80 40 111 112 E-mail: hospitalempanelment@spurthimeditech.com / Web: www.spurthimeditech.com

I. 2. Inpatient Cases. Specialty Name Total Number of Inpatient admissions during calendar year >750 per year

General medicine

THIS INFORMATION COLLECTED WOULD BE KEPT CONFIDENTIAL AND THIS WILL BE USED ONLY FOR EMPANELLING YOUR HOSPITAL WITH SPURTHI MEDITECH (TPA) SOLUTIONS PRIVATE LIMITED AND NOT FOR ANY ANOTHER PURPOSES
Empanelling into Spurthi Meditech (TPA) Solutions Private Limited does not necessarily assure you 100% of business. It is an opportunity for your business to grow but our intention is only to provide wider options for the customer to choose from and gives you a benefit of servicing all our customers health that is covered by our services.

WE THANK YOU AND YOUR TEAM FOR GIVING YOUR VALUABLE TIME AND DATA
Our team will scrutinize the data produced and shall revert back to you for further or next level of SLA and Business Continuity Plan with Provisional/Suggested Package Rates for medical and surgical interventions/procedures with Codes.

Regd. Office: No. 82 | Maruthi Ramakrishna Arcade | 2nd Floor | Dr. Rajkumar Road | Rajajinagar 2nd Block Bangalore-560 010. Phone: +91 80 40 111 111 | +91 80 40 505 050. Fax: +91 80 40 111 112 E-mail: hospitalempanelment@spurthimeditech.com / Web: www.spurthimeditech.com