Reciept Nursing Home

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Applicant Details

Application Number	NHS2114207	Application Type	NEW
Applied Date	13/10/2021
Applicant's Name	RAMPRASAD PANWAR	DOB(DD/MM/YYYY)	23/03/1985
Mobile Number	8817769069	Email	samyakhospital03@gmail.com
Technical Qualification	Other	Nationality	Indian
Full residential address of the Applicant	04 ,GULAB MARKET SAJJAN MILL ROAD ,RATLAM Ratlam(NagarNigam) RATLAM 457001
Type of Ownership	Proprietor

Signing Authority Details
Name of Signing Authority	RAMPRASAD PANWAR	Designation of Signing Authority	OWNER
ID Card	Aadhaar Card	ID Card No.	908049801895

Nursing Home Details

Name of the Nursing Home in respect of which the registration is applied for		SAMYAK HOSPITAL
Type of Institutions for which Registration is being applied		Allopathy
Firm/Company Registration No.		Website Address
Date of Establishment	12/10/2021
Type of Specialty	Multiple

Details of the Procedure/Services

Procedure/Services	Details	Remarks
Internal Medicine	INTERNAL MEDICINE
Physiotherapy & Rehabilitation	PHYSIO AND REHAB
Other : day care center	DAY CARE CENTER
Other : GENERAL MEDICINE	GENERAL MEDICINE

Place where the Nursing Home is situated

18-19 ,GULAB MARKET RAM MANDIR CHORAHA ,RATLAM Ratlam(NagarNigam) RATLAM 457001

Whether the applicant is interested in any other Nursing Home or business?

Infrastructure Details

Details of Rooms For Employees

Room Type	Floor Space/Area (in sq. ft)	Number of Rooms	Remarks
Duty room for Doctor	48	1

Details of Unit/ward

Unit/Ward	Floor Space/Area (in sq. ft)	No. of Beds in the Unit (without oxygen support)
General Ward	706	11
General Ward	788	11
Private/Deluxe unit	81	1
Private/Deluxe unit	84	1
Semi Private/Semi Deluxe unit	138	2
Private/Deluxe unit	81	1
Private/Deluxe unit	84	1
Semi Private/Semi Deluxe unit	138	2
Private/Deluxe unit	92	1
Private/Deluxe unit	84	1
Semi Private/Semi Deluxe unit	165	2
Private/Deluxe unit	92	1
Private/Deluxe unit	84	1
Semi Private/Semi Deluxe unit	165	2
Semi Private/Semi Deluxe unit	184	2
Private/Deluxe unit	112	1
Private/Deluxe unit	110	1
Semi Private/Semi Deluxe unit	184	2
Private/Deluxe unit	112	1
Private/Deluxe unit	110	1
ICU	353	4
OPD Room	96	0
OPD Room	96	0
OPD Room	80	0
OPD Room	80	0
OPD Room	80	0
OPD Room	80	0
Other : MINOR OT	96	0

Total Number of Beds : 50

Sanatary Convenience For Employees

Sanitary Arrangement	No. of Toilets	Remarks
Indian Style	3

Sanatary Convenience For Patients

Sanitary Arrangement	No. of Toilets	Remarks
Functional and clean toilets with running water and flush	17
Bed pan washing sinks	30
Continuous water supply	1

Arrangements for Immunization of the employees are available or not?			Yes
Arrangement made for Medical check-up of the employees			Yes
Regular immunization & Health Checkups are being held in the interval of(in Month)			6
Arrangements made for storage of Food	Refrigerator	Service of food	No Service
Whether the nursing home or any premises used in connection there with are used or are to be used for purposes other than that of carrying on a nursing home			No

Staff Details

Staff Type	Registration Status	Name	DOB	Qualification	Registering Authority	Registration No.
Registered Resident Medical Practitioner	Permanent	Mr. DR SURESH KUMAR VERMA	02/06/1995	M.B.B.S (Bachelor of Medicine/Bachelor of Surgery)	MPMC	MP-28346
Registered Resident Medical Practitioner	Permanent	Mr. DR HANSRAJ PARMAR	01/01/1995	M.B.B.S (Bachelor of Medicine/Bachelor of Surgery)	MPMC	mp-28146
Registered Resident Medical Practitioner	Permanent	Mrs. DR NEELAM MAIDA	17/02/1989	M.B.B.S (Bachelor of Medicine/Bachelor of Surgery)	MPMC	16103
Nursing Staff	Permanent	Ku. CHANDRAKALA CHAVAND	15/04/1984	Other :	MP Nurses Registration Council	V-71138
Nursing Staff	Permanent	Mr. DEEPAK JOSHI	02/07/1995	Other :	MP Nurses Registration Council	V-71913
Nursing Staff	Permanent	Mr. JALAM SINGH	01/02/1982	Other :	MP Nurses Registration Council	V-72602
Nursing Staff	Permanent	Ku. LEELA DODIYAR	23/05/1996	Other :	MP Nurses Registration Council	V-71914
Nursing Staff	Permanent	Mr. PRADEEP MORYA	25/02/1996	Other :	MP Nurses Registration Council	V-72261
Nursing Staff	Permanent	Ku. RADHA SOLANKI	27/08/1988	Other :	MP Nurses Registration Council	V-72267
Nursing Staff	Permanent	Ku. SHALU MARMAT	13/07/1996	Other :	MP Nurses Registration Council	V-71153
Nursing Staff	Permanent	Ku. SHALU KUMARI RAO	07/02/1996	Other :	MP Nurses Registration Council	V-71915
Nursing Staff	Permanent	Ku. SONIKA PARMAR	05/08/1999	Other :	MP Nurses Registration Council	V-66554
Nursing Staff	Permanent	Ku. ANITA KATARA	01/01/1992	Other :	MP Nurses Registration Council	AI-44707,DII-44057
Nursing Staff	Permanent	Ku. ANITA BHURA	24/06/1997	Other :	MP Nurses Registration Council	AI-45076,DII-44426
Nursing Staff	Permanent	Mr. DAYARAM MEENA	30/11/1998	Other :	MP Nurses Registration Council	AI-44777,DII-44127
Nursing Staff	Permanent	Ku. JYOTI GURJAR	08/03/1998	Other :	MP Nurses Registration Council	AI-44710,DII-44060
Nursing Staff	Permanent	Ku. KIRAN GARGAMA	09/12/1998	Other :	MP Nurses Registration Council	AI-44775,DII-44125
Nursing Staff	Permanent	Ku. PAYAL VERMA	16/10/1993	Other :	MP Nurses Registration Council	AI-32806,DII-32156
Nursing Staff	Permanent	Ku. PRIYA NAYMA	10/02/1997	Other :	MP Nurses Registration Council	AI-44776,DII-44126
Nursing Staff	Permanent	Ku. REENA NAYMA	10/06/1997	Other :	MP Nurses Registration Council	AI-44779,DII-44129
Nursing Staff	Permanent	Mr. YOGENDRA SINGH	10/05/1997	Other :	MP Nurses Registration Council	AI-44772.DII-44122
Nursing Staff	Permanent	Mr. HARIKISHAN	03/07/1992	Other :	MP Nurses Registration Council	AI-27949,DII-27299

Whether on campus availability of accommodation of Nursing Staff : No

Whether any Unregistered Medical Practitioner or Unqualified Nurse, Unqualified Midwife is employed for nursing of patient in the Nursing home : No

Unqualified Staff details

On campus chemist shop available : Yes

Name of Chemist Shop

SHRI BALAJI MEDICAL STORE RATLAM

License No of Chemist Shop

20/957/22/2020,21/958/22/2020

Equipments and Fee Details

Charges For	Fees
Other : CATHERIZATION	200
Other : R/T	200
Other : OPD CHARGES	300
Other : IPD CHARGE GENERAL WARD	500
Other : IPD CHARGE SEMI PRIVATE WARD	700
Other : IPD CHARGE PRIVATE WARD	1000
Other : IPD ICU	1500
Other : DAY CARE	200
Other : DRESSING	100
Other : INJECTION	50

Equipments Details

Equipment	Model / Type	No of Equipment/No of Cylinders/Capacity in Matric Tons
Other : ECG MACHINE	NA	1
Other : SP O2	NA	1
Other : BP INSTRUMENT	NA	1

Uploaded Documents Details

1. List of Visiting Doctor(s)

2. Authorization By Pollution Control Board

3. Building permission

4. Temporary Fire Noc

5. Common Biomedical Waste Treatment Facility Agreement

6. Any Other Related Document1

7. Any Other Related Document2

8. MPMC Registration of RRMP(s)

9. MPMC / Additional MPMC Registration of Visiting Doctor(s)

10. Updated Rate List of All Services (Photograph of displayed rate list)

11. Photograph of the Nursing Home Premises ( Front facade)

12. Photograph of Wards and Utilities (Picture collage of wards and utilities)

13. Approved Floor Plan of Building

14. Electrical Safety Certificate

15. MTP Registration Certificate (If MTP services are provided)

16. PCPNDT Registration Certificate (If USG or Imaging modalities are provided)

Fee Details

App Fee		0.00
Portal Charge		50.00
Total Fee		50.00

Transaction Details

Application Number	NHS2114207	Transaction ID	21113004343206130978
Transaction Date	30/11/2021	Payment Status :	Yes