Jan 22 2017

IMA Hospital Board of India,Maharashtra

IMAMaharashtraState.org @ 1:57 am

IMA HBI MS Membership Form

Model_ byelaws_for_State_chapters

 

HOSPITAL BOARD OF INDIA MAHARASHTRA CHAPTER

(Under The Aegis Of Indian Medical Association HBI HQ)

Office – IMA (MWS) Building, Juhu, Mumbai – 4400 049 M.S.

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

                                   

Dr. Ashok Tambe         Dr.Parthiv Sanghvi          Dr. Dinesh Thakare         Dr. saurabh Sanjanwala

President,                     Secretary,                                             Chairperson,                 Secretary,

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

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M E M B E R S H I P   F O R M

 

Name Of Applicant Hospital:_______________________________________________________

Hospital Registration No. as per Bombay Nursing Home Registration Act  __________________

Name Of Hospital Owner (IMA Member):-______________________________________________

Mob:-1)______________________2)______________________Hospi.No.____________________

E-mail:-_________________________________________________________________________

MMC Registered Qualification:_______________________________________________________

IMA LM Number:__________________________________________________________________

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__________________

Services Provided :- ______________________________________________________________

__________________________________________________.Signature:____________________

 

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Affiliation Fees:-                                                                                                                      

 

Type Of Institute No. Of Beds HBI MS Fee (One Time) HBI HQ Fee(For 5 years) Affiliation Fee(For Five Years) Total
Primary Health Care Institution No IPD Rs.500 Rs.500 Rs.500 Rs.1,500
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

 

HBI IMA Local Sub-Chapter Fee (Additional) :- To be decided by the local executive committee.

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

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

ii)Local Municipal Corporation Regi. Certificate &

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

3)Please attach additional sheet if necessary.

4)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:-

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