Paramount Health Services & Insurance TPA Pvt. Ltd.

We would like you to be a part of our Provider Network. To empanel your hospital, please fill this provider enrollment request form completely and accurately.

Note:

All fields marked with * are mandatory
The submission of this form in no way guarantees the empanelment on PHS network
As per IRDA Regulations, cashless facility will be provided only to those hospitals that have valid ROHINI registration ID.
After registration, kindly share your ROHINI ID with Paramount.

Basic Detail

Provider Name :

Established in the year :

Category Code :

Level Of Care :

Speciality Type :

Specialized In :

Teaching Institute :

Use of HMIS :

Address Details

Address :

Address Area :

Landmark :

City :

State :

Pin Code :

District :

Communication Details

Tel. Area Code :

Tel. No :

Fax No :

Mobile No :

Email Id :

Web Address :

Details

PAN N0 :

Name of PAN account holder :

TAN no. :

Name of TAN account holder :

Service Reg.no. :

Hospital Reg.no. :

Type Of Hospital :

Rohini Code :

Additional Information

Area Built Up :

Sq ft

Open Area :

Sq ft

Bed Capacity :

NO. of Rooms :

No. of ICU Beds :

No. Of OT's :

Waiting Area

Car Parking

TDS Exemption Certificate from Income Tax

Ac/Non Ac

Ambience Cleanliness

Examination Room

Exem from 17_2_B Income Tax :

Bank Account Details

Name of Account Holder * :

Account Number * :

Bank Name * :

Branch Address :

IFSC Code * :

Bank Details * :

ACCREDIATION & CERTIFICATION Details

NABH Certified :

JCI Certified :

Other Accrediated :

ISO Accrediated :

Tariff * :

Hospital Registration Certificate * :

Remarks :