All the private clinical establishments shall implement all the National Health Programmes launched by the Government of India from time to time and shall submit periodical reports to the health authorities concerned in the specified pro forma.
(By order of the Lieutenant-Governor) V. JEEVA, Under Secretary to Government (Health).
62 LA GAZETTE DE L'ETAT [PART–II FORM-‘A’ GOVERNMENT OF PUDUCHERRY DEPARTMENT OF HEALTH AND FAMILY WELFARE SERVICES APPLICATION FOR PROVISIONAL REGISTRATION OF CLINICAL ESTABLISHMENTS [Section 14 (1) and 14 (3) of the Act]
1. Name of the establishment or :
doctor (in case of single practitioner).
2. Address :
PIN code :
Tel. No. (with STD code) : Mobile :
Fax : e. mail :
Website (if any) :
3. Year of starting :
4. Location : Urban/Rural
5. Ownership of services :
(a) Public Sector Central Government/State Government/Local Government Public Sector undertaking/Railways/Employee State Insurance Corporation (ESIC)/ Autonomous organisation/Society/Not for profit companies.
Any other (please specify) :
(b) Private Sector Individual proprietorship/[Registered partnership/Registered company/Corporation (including a Society) registered under a Central, Provincial or State Act (please specify) :
Trust (including charitable) registered under a Central, Provincial or State Act (Please specify) :
Branch of a Foreign Service provider (please specify)...................
63PART–II] LA GAZETTE DE L'ETAT
6. Name of the owner :
Address :
PIN code :
Tel. No. (with STD code) : Mobile : Fax :
e.mail :
7. N a m e , d e s i g n a t i o n a n d qualification of person in-charge of the clinical establishment— Name of person in-charge :
Designation : Qualification :
Registration No. and name of :
the Council Address :
PIN code :
Tel. No.(with STD code) : Mobile : Fax :
e.mail :
8. System of medicine offered :
(Please specify).
(i) Allopathy, (ii) Ayurveda (iii) Unani, (iv) Siddha,
(v) Homeopathy, (vi) Yoga and Naturopathy,
(vii) Any other (please specify):
9. Type of establishment: (Please tick whichever is applicable) Clinic Single practitioner/Polyclinic Medical Termination of Pregnancy (MTP)/Dental/Mobile/Any other (please specify) :
64 LA GAZETTE DE L'ETAT [PART–II Centre:
Sub-Centre Primary Health Community Health Urban Health Centre Centre. Centre.
Counseling Centre Dispensary Day care Centre In Vitro Fertilization (IVF) Wellness Centre Dialysis Centre. Hospice Centre Any other (like Refraction Audiometry, Prosthetic and Orthotic etc., please specify) :
Diagnostic Centre Laboratory:
Pathology Hematology Histopathology Cytology Genetics Sample Collection Centre.
Any other (please specify):
Biochemistry/Microbiology, Any other (please specify):................
Imaging Centre:
Portable X ray Conventional X ray X ray with computerised Radiography Digital X ray system. Ultrasound Ultrasound with color doppler. Mammography CT Scan Orthopentogram(OPG)/ Magnetic Resonance Imaging (MRI).
Positron Emission Tomography (PET) Scan. Bone Densitometry Uro-flowmetry Any other (Please specify) :
Miscellaneous Electro Cardio Graphy (ECG) Echo cardiography Tread Mill Test Electro Myo Graphy (EMG) Electro Encephalo Graphy (EEG) Electrophysiological studies Any other (please specify):
Blood banks (A) Based on location Stand alone Hospital based Any other (please specify):
65PART–II] LA GAZETTE DE L'ETAT (B) Based on facilities Blood bank/Centre having whole blood facility only.
Blood bank/Centre having whole blood and component facility.
Blood bank/Centre having whole blood and/or component facility.
with any other additional facility (please specify): ........................
Hospital General Practice Services Maternity Home Clinic Specialty Services Multi Specialty Services Super Specialty Services O p e r a t i o n T h e a t e r Emergency /Causa l i ty ICCU ICU Any other please specify): ....................................................
Sanatorium Any other (please specify): ....................................................
SYSTEM OF MEDICINE
10. Services offered (please tick whichever is applicable)
(a) Allopathic Specialty Medical Surgical Obstetrics and Gynaecology Paediatrics Any other please specify :......................................
(b) Ayurveda Ausadh Chikitsa Shalya Chikitsa Shodhan Chikitsa Rasayana Pathya Vyavastha.
Any other please specify: .........................................................
(c) Unani Matab Jarahat Ilaj-bit-Tadbeer Hlfzan-e-Sehat Any other please specify: ........................................................
(d) Siddha Maruthuvam Sirappu Maruthuvam Varmam Thokknam and Yoga Any other please specify : .........................................................
66 LA GAZETTE DE L'ETAT [PART–II
(e) Homoeopathy General Homeopathy Any other please specify :...........................
(f) Naturopathy External Therapies with natural modalities Internal Therapies Any other please specify: .........................................................
(g) Yoga Ashtang Yoga Any other please specify: ............................
INFRASTRUCTURE DETAILS:
11. Area of the establishment (in Sq. meters):
(a) Total area :...................... (b) Constructed area:.......................
12. Out-patient Department
12.1 Total No. of OPD clinics : .....................................................
13. In-patient Department:
13.1. Total number of beds: ..................................
13.2. Specialty-wise distribution of beds, please specify: ...............
Sl.
No.
Specialty No. of rooms Sl.
No.
Specialty No. of rooms 67PART–II] LA GAZETTE DE L'ETAT
14. Bio-medical waste management
14.1. Method of treatment and/or disposal of Bio-medical waste Through common facility Onsite facility Any other please specify: ..................................................
14.2. Whether authorisation from Pollution Control Board/ Pollution Control Committee obtained?
Yes No Applied for Not applicable HUMAN RESOUCES :
15. Total number of staff (as on date of application):
No. of permanent staff : ............. No. of temporary staff :...........
Please furnish the following details:- Separate annexure may be attached.
16. Payment option for registration fees:
Online payment Demand Draft Postal Order Any other (please specify): .........................................
Amount (in `): .............................................................
Details : ...............................
Receipt No : ........................
Category of staff Name Qualification Registration No.
Nature of service permanent/ temporary Doctors Nursing staff Para-medical staff.
Pharmacist Support staff Others, please specify.
68 LA GAZETTE DE L'ETAT [PART–II I hereby declare that the statements above are correct and true to the best my knowledge and I shall abide by all the rules and declarations under the Clinical Establishments Registration and Regulation) Act, 2010.
I undertake that I shall intimate to the appropriate registering authority any change in the particulars given above:
Place: Signature of the authorised signatory Date: Office seal.
———— FORM - ‘AA’ GOVERNMENT OF PUDUCHERRY DEPARTMENT OF HEALTH AND FAMILY WELFARE SERVICES REGISTRATION OF CLINICAL ESTABLISHMENT ACKNOWLEDGMENT FOR RECEIPT OF APPLICATION [See rule 5(4)] The application for grant/renewal of Provisional/Permanent Registration of the Clinical Establishment submitted by.....................
.......................................................................................................................
(Name and address of owner) has been received by the District Registering Authority on ...................................... (date) and found to be complete or incomplete.
This acknowledgment does not confer any right on the applicant for grant or renewal of registration.
Seal : Signature and designation of Date : registration authority or any authorised person by the registering authority.
69PART–II] LA GAZETTE DE L'ETAT FORM - ‘AB’ GOVERNMENT OF PUDUCHERRY DEPARTMENT OF HEALTH AND FAMILY WELFARE SERVICES FEES TO BE PAID FOR REGISTRATION/ RENEWAL OF CLINICAL ESTABLISHNMENT [Sections 14 (1), 19, 20(2), 24 and 35 of the Act] Description Urban Rural Provisional Permanent Provisional Permanent (yearly) (for a period (yearly) (for a period of 5 years) of 5 years) ` ` ` ` Out-patient care 1,000 3,000 500 1,500 In-patient care 1 to 9 beds 2,000 5,000 1,000 3,000 10 to 29 beds 5,000 10,000 2,500 5,000 30 to 99 beds 10,000 20,000 5,000 10,000 100 beds and 20,000 40,000 10,000 30,000 above.
Diagnostic/Testing Laboratories 1,000 2,000 500 1,000 Diagnostic 1,500 3,000 1,000 2,000 and Imaging (X-ray/ECG).
Ultrasound 2,000 4,000 1,500 3,000 Scan Centre.
Blood Bank 2,000 4,000 1,000 2,000 CT Scan 10,000 15,000 5,000 10,000 Centre MRI Scan 15,000 30,000 10,000 20,000 Centre.
70 LA GAZETTE DE L'ETAT [PART–II Other fees :
* For renewal same amount of registration fee (provisional/permanent).
* For late application the amount would be double of the registration fee (provisional/permanent) along with penalty.
* For duplicate certificate the amount would be ` 500.
* For change of ownership, management or name of establishment would as that of registration fee.
* For any appeal the amount would be ` 5,000.
If a laboratory or diagnostic centre is a part of a establishment providing out-patient/ in-patient care no separate registration is required.
———— FORM-‘R’ GOVERNMENT OF PUDUCHERRY DEPARTMENT OF HEALTH AND FAMILY WELFARE SERVICES PROVISIONAL CERTIFICATE FOR REGISTRATION OF CLINICAL ESTABLISHMENT [Section 15 of Act and rule 5(5)] Provisional Registration No:
Date of issue :
Valid up to :
1. M/s./Doctor ...............................................(name of the clinical establishment) operating from...................................(complete address) as ..............................................................................................................
..............................................(type of clinical establishment) is hereby provisionally registered under the provision of Clinical Establishment (Registration and Regulation) Act, 2010 to provide service under ......................system of medicine with ............................(bed strength).
2. This authorisation is subject to the conditions stated and to such other conditions as may be specified in the rules in force under the Clinical Establishments (Registration and Regulation) Act, 2010.
Place : Name and designation Date : of the registering authority:
Terms and conditions of registration*
1. The holder of this certificate of registration shall comply with all the provisions of Clinical Establishment (Registration and Regulation) Act, 2010 and the rules made thereunder.
71PART–II] LA GAZETTE DE L'ETAT
2. The certificate of registration is not transferable.
3. Any change of ownership or change of category or change of management or on ceasing function as a clinical establishment, the certificate of registration shall be surrendered to authority and application for fresh registration may be submitted.
4. The certificate of registration shall be displayed in a prominent place in a part of the premises open to public.
* Additional terms and conditions are as stipulated by the appropriate registering authority.
———— FORM - ‘O’ GOVERNMENT OF PUDUCHERRY DEPARTMENT OF HEALTH AND FAMILY WELFARE SERVICES REGISTRATION OF CLINICAL ESTABLISHMENT DISPLAY OF INFORMATION FOR FILING OBJECTIONS [Section 26 and see rule 7(3)] I, ....................................................... being the District Registering Authority under the Clinical Establishment Act, 2010 after considering the applications received during the period; from ................................
to ....... ..................... under section 24, satisfying the provisions of the Clinical Establishment Act, 2010 and the Clinical Establishment Rules, 2014 made thereunder, hereby publish the list of clinical establishments; within the jurisdiction of ........................... district.
Sl. Name of clinical Ownership/ System of Date on Category and No. establishment in-charge medicine which standards with address application complied was with submitted Objections, if any, in writing to the published list may be addressed in duplicate to ............................................................................(address of the authority) within 30 days from the date of this notification.
Place: Signature:
Date: Name:
(Seal of the authority) 72 LA GAZETTE DE L'ETAT [PART–II FORM-‘IR’ SUGGESTED FORMAT FOR SUBMISSION OF INSPECTION REPORT [Section 33 and see rule 9(4)] Number of visits made with dates:
Names and details of members of the inspection team Name of clinical establishment visited Address and contact details of clinical establishment visited Process followed for inspection (e.g. kindly outline who was met with, what records were examined, etc.)
Salient observations/findings Conclusions Specific recommendations— To the Clinical Establishment To the District Registering Authority In case of lack of consensus amongst members of the inspection team, the same may be kindly indicated Signature (of all members of the inspection team).
Place :
Date :
73PART–II] LA GAZETTE DE L'ETAT FORM - ‘APL’ [Section 36(2) of Act and rule 12(1)] To The Member-Secretary, Puducherry Council for Clinical Establishments, Government of Puducherry Sir, I, ........................................................................... had applied for registration under Clinical Establishments Act, 2010 for ................
(name of the establishment) .............................................................
.....................................................................located at .................................
(address of the establishment) I, ....................................................... owner of the .................. of the establishment (name of the establishment) ......................................
located at ............................................. is a valid licence holder with Registration No. ................................ under the Clinical Establishment Act, 2010.
I was communicated by the District Registering Authority vide Order No. ................................., dated ................... that either;
(i) That my application was rejected
(ii) That my registration is cancelled
(iii) I am restrained from carrying on with the running of clinical establishment.
(iv) That I am charged with a penalty for an offence under the Act
(v) Any other .....................................................................................
74 LA GAZETTE DE L'ETAT [PART–II The above decision of the District Registering Authority appears to be not valid and I request to consider my application as per the justification mentioned below:
(i) .............................................................................................
(ii) ............................................................................................
(iii) ...........................................................................................
I am willing to appear before you for a personal hearing, if necessary. I am enclosing herewith a draft of ` 5,000.
Thanking you Place: Signature :
Date: Name :
Name of the Clinical Establishment :
(1) Address :
(2) Owner of the clinical establishment :
(3) Name of person in-charge :
(4) System of medicine :
(5) Type of establishment :
is hereby provisionally registered under the provisions of Clinical Establishments (Registration and Regulation) Act, 2010 and the rules made thereunder.
This authorisation is subject to the conditions as specified in the rules in force under the Clinical Establishments (Registration and Regulation) Act, 2010 and the rules made thereunder.
Place : Designation of the issuing authority:
Date :
District Registration Authority Address:
Phone number in case of grievances 75PART–II] LA GAZETTE DE L'ETAT FORM - ‘REG’ RECORDS TO BE MAINTAINED BY CLINICAL ESTABLISHMENTS The various medical records to be maintained by the clinical establishment are as follows:- * Out-patient register * In-patient register * Operation Theatre register * Labor room register * MTP register (If register under the MTP Act) * Case sheets * Medico-legal register * Laboratory register * Radiology and imaging register * Discharge summary * Medical certificate in duplicate * Complaint register * Birth register * Death register (in such format as prescribed by Government) * Information in terms of Government programme/areas of work (e.g., maternal health, child health, immunisation, family planning, vector borne disease, NLEP, RNTCP, IDSP, NRHM initiatives-ASHA, JSY).
* Number of beds system-wise and specialty-wise providing in-patient care (e.g. General Bed/Surg Beds, Special Care Beds) * Total discharges.
76 LA GAZETTE DE L'ETAT [PART–II FORM- ‘RATE’ MINIMUM LIST OF SERVICES FOR WHICH RATES ARE TO BE DISPLAYED Name of the service Type of service Charges (in `)
(1) (2) (3) Room Charges: General services (includes room/bed charges, Private rooms:
Nursing charges, Medical Semi Deluxe - shared Utilities charges). Deluxe with AC.
Intensive Care Units: MICU & ICU (Charges include the ICU NEURO bed charges, medical utilities, POW monitoring and nursing Neonatal ICU charges). Paediatrics ICU OT Charges :
General Anesthesia ½ hour General ward twin/triple sharing.
General Anesthesia 1 hour General ward twin/triple sharing.
Local Anesthesia ½ hour 1 hour Surgical procedures charges General surgical procedures (package) (includes surgeon Ob & Gy procedures charges+Anesthetist charges* Orthopaedic surgical procedures Nursing home charges and Cardiac surgical procedures in-patient medicine charges).
Doctor consultation charges: OP Specialist Super Specialist.
IP Per visit Emergency visits Per visit Emergency care team charges 3 shift per day 77PART–II] LA GAZETTE DE L'ETAT Diagnostic charges ` Common diagnostic tests X-ray per film Ultra sound, General and Abdomen Obstetrics care Female pelvic KUB CT Scan: Brain Plain Multi slice/ Spiral /CT Scan Chest/Abdomen/Neck/ Spine.
MRI 0.5/1/1. 5 Brain (Magnetic Resonance Chest Imagin) Contast ECG/TMT/ECHO/EMG/EEG Upper GI Endoscopy/Lower GI Endoscopy Lab. investigation Random blood sugar Serum creatinine CBP/ESR/CUE Blood Group Blood for MP LFT Lipid profile HBSAG/VDRL/HIV Electrolytes T3,T4,TSH Any other items (not included above).
Note: Other service charges for in-patient such as drug and disposables, investigation and concession, if any, shall be displayed at appropriate places for the benefits of the patient.
(1) (2) (3) 78 LA GAZETTE DE L'ETAT [PART–II CG3 ANNEXURE State/District Register for Clinical Establishment Details of Information Required (A) At State/District level:
Total number of establishment by - Category - System of medicine practiced - Type of service provided - Rural/Urban - No. of beds Number of clinical establishments increased or decreased Number of inspections carried out Number of pending application with reasons Action taken against non-register establishments operating in violation of the Act.
Complaint received by the State Council under the Act and action taken pursuant thereto.
(B) Detailed information Details of each clinical establishment by Name Location containing details Rural/ Urban/Metropolitan Village/Town Taluka District State PIN code Phone number 79PART–II] LA GAZETTE DE L'ETAT e-mail ID:
Ownership details Name of owner Educational qualification Person in-charge of clinical establishment Education qualification Urban/Rural designation Longitude/Latitude systems of medicine offered Type of establishments by category specified under section .............
of the ..............rules. Nature of service provided by category specified under section ..............of the...............rules.
Number of beds system-wise and specialty-wise in clinical establishments providing in-patient care.
Total employees.
Total discharging:
Average length of stay (OP/IP) Utilisation statistics Details of staff with name, qualification, Registration number, temporary or permanent.
———— online publication at “http://styandptg.puducherry.gov.in” Government Central Press Directorate of Stationery and Printing Puducherry-9.