Apr 22 2017

IMA Hospital Board of India,Maharashtra

IMAMaharashtraState.org @ 1:57 am

   

FORMS : IMA HBI MS Membership Form 

IMA-HBI-NABH INITIATIVE-2

NABH Enrolment Form MAHARASHTRA

HOSPITAL BOARD OF INDIA MAHARASHTRA CHAPTER

(Under The Aegis Of Indian Medical Association HBI HQ)

Office – IMA Maharashtra State, Mumbai West Bldg., 2nd Floor, J.R. Mhatre Marg,

 JVPD Scheme, Juhu, Mumbai – 400 049 Tel: 022-26232965, 022-2623890

  Website – www.imahbims.org; e-mail:- imahbims@gmail.com

                                   

            Dr. Y.S. Deshpande   Dr. Parthiv Sanghvi      Dr. Dinesh Thakare   Dr.Saurabh Sanjanwala      Dr. Mangesh Pate

President,                   State Secretary,             Chairman,                       Secretary,                               Treasurer,

IMA, MS                       IMA, MS                       HBI, MS                          HBI, MS                                 HBI, MS

 

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          AFFLIATION APPLICATION  F O R M

 

            Details of Applicant Medical Establishment :______________________________________________

            Name of Establishment : ______________________________________________________________

Registration No:  ____________________________________________________________________

Name of Hospital Owner (IMA Member):-__________________________________________________

MMC Registered Qualification:__________________________________________________________

IMA LM Number:_____________________________________________________________________

Registered Qualification No : ____________________________________________________________

Mob:-1)______________________2)____________________Hospi.No.________________________

E-mail:-____________________________________________________________________________

            Category Of Hospital:- (Plz tick mark)

1) Primary Health Care Institution (Clinic Without Inpatient Care)                                                                                      2) Secondary Health Care institution (Institution With Secondary Care)

3) Tertiary Health Care institution (Institution With Tertiary Care)

            Strength Of Hospital Beds:- (Plz tick mark) 1)0 -20 beds, 2)21 – 50 beds, 3)More Than 50 beds

            No. Of Qualified Paramedical Staff:-          _______          No. Of Non-medical Staff :- _______

            No. Of Non-qualified Paramedical Staff:- _________

            Details Of Working / Attached Allopathic Doctors:-

Allopath’s Name  IMA LM Number MMC Registered Qualification Signature
       
       
       
       

 

 

Address Of Hospital:-__________________________________________________________________

__________________________________________________________________________________

_________________________Pin Code__________________  Sign. & Stamp of Owner( IMA Member)

Services Provided :- __________________________________________________________________

___________________________________________________________________________________

 

            ***************************************************************************************************************************

            Affiliation Fees:-

 

Type Of Institute No. Of Beds HBI MS Fee (for 5 years) Rs 100/- per year HBI Entry Fees (once only) HBI State Chapter Affiliation Fee

 

Total Fee for 5 years (A)
Primary Health Care Institution No IPD Rs.500 Rs.500 Rs.500 Rs.1500
Secondary / Tertiary Health Care Institution 0 – 20 Beds Rs.500 Rs.500 Rs.2,500 Rs.3,500
21 – 50 Beds Rs.500 Rs.500 Rs.5,000 Rs.6,000
> 50 Beds Rs.500 Rs.500 Rs.10,000 Rs.11,000

           

Additional Rs. 1500 per local (working / attached) member for 5 years.

The Local member will not have right to vote or to hold any HBI Post

No of Local members _________ x Rs. 1500 = (B) Rs. ______________

Mode of Payment:- ________________ Total (A + B)= Rs. __________

            ***************************************************************************************************************************

            Note:- 1)Membership forms must be sent through local IMA branch only.

            2) Please attach true copies of   i) IMA LM Certificate,

  1. ii) Local Municipal Corporation Regi. Certificate &

            iii) MMC Regi. Certificate of PG Degree of all doctors.

            3) Please attach additional sheet if necessary.

           

Please issue the at par cheque / DD in the name of “IMA MS HBI” payable at Mumbai.

 

====================== For Local Branch Office Use Only =======================

Sub-Chapter Serial No._______

Verified By:-________________________________ Signature:-___________________________

(President / Secretary Of IMA Local Branch)                        Seal:-

========================= For HBI MS Office Use Only ========================

State Affiliation No.__________                                             IMA HQ Affiliation No.______________

Verified By:-________________________________            Signature:-___________________________

(Hon. Secretary, IMA HBI MS Chapter)                                            Seal:-

========================= For HBI HQ Office Use Only ===============================

IMA HBI MS Chapter serial No. __________

Verified By:-________________________________            Signature:-___________________________

(Hon. Secretary of IMA HBI Hqs)                                          Seal:-

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