APPLICATION
For
Accreditation Programme for CLINICs-
Allopathy-Modern practice of Medicine
Issue No.: 02
Issue Date: April 2012
NATIONAL ACCREDITATION BOARD FOR
HOSPITALS and HEALTHCARE PROVIDERS
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NATIONAL ACCREDITATION BOARD FOR
HOSPITALS and HEALTHCARE PROVIDERS
Assessment criteria and Fee structure
Size of Clinic Assessment Criteria Accreditation Fee
*On-site Surveillance Application Fee Annual Fee (to
Assessment (not-refundable) be paid at the
time of
accreditation
and then
yearly)
One man One man day
Clinic/dispensary Rs. 5,000/- Rs. 15.000/-
day
Clinic/dispensary One man day
with additional
services
or
Polyclinic Rs. 10,000/- Rs. 20,000/-
or
Polyclinic with
additional Two man
services days
*the fee structure is nominal and is based on the number of man days required for
assessment. In case the scope of services is more than the above, then proportionately
higher man days and fee structure may be charged.
Service Tax: w.e.f. 15.11.2015 a service tax of 14.50% will be charged on all the above fees.
You are requested to please include the service tax in the fees accordingly while sending to
NABH.
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Guidance notes on Accreditation Fee:
1. Fees to be paid through Demand Draft/ local cheque in favour of Quality Council of India
payable at New Delhi. Fees are non-refundable.
2. Five copies of this application form duly filled in are to be submitted along with
necessary documents and fees.
3. Self Assessment Toolkit dully filled in is to be submitted by the Clinic along with the
application form.
4. The accreditation fee does not include expenses on travel, lodging/ boarding of
assessors, which will be borne by the Clinic on actual basis.
5. With a view to keep the expenses to be borne by the clinic at a minimal level NABH will
try and ensure the assessors from the same or nearby city/town.
6. In case the clinic is located in a remote area where local assessor is not available an
effort will be made to find the nearest located assessor(s) by NABH and the clinic will arrange
their transportation by car/taxi/train/air and boarding and bear the cost for the same. As the
demand for accreditation rises, NABH will facilitate two or more assessments simultaneously
thus helping with sharing of cost between the clinics.
7. The application fee includes assessment charges.
8. The accreditation, once granted will be valid for three years, after which clinic will apply
afresh.
9. The first annual fee is payable after the clinic has successfully undergone an
assessment and recommended for grant of accreditation by NABH. NABH will inform the clinic
regarding the same and the clinic will send the annual fee after which formal Accreditation
Certificate will be issued.
10. 10% discount will be admissible in case the Clinic pays the accreditation fee for three
year in one instalment.
11. The accreditation certificate along with the scope of services shall be displayed
prominently at the clinic.
12. The surveillance visit will be planned during the 2nd year of the Accreditation cycle.
13. NABH may call for one un-announced visit, based on any concern or any serious
incident reported upon by any individual or organization or media.
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Guidelines for filling the application form
(Please read this carefully before filling this form)
1. Kindly fill the application form in BLUE/BLACK INK only. You can also submit a printed
version of the filled application form.
2. For Sl. No. 3- Kindly mention if the organisation is a public/ government establishment or an
independent/ private sector provider.
3. For Sl. No. 6- Please specify e.g. clinical establishment, shop, etc.
4. For Sl. No. 8- Please tick the clinical service(s) being provided by the clinic, as the same will
be considered as scope of service(s).
5. For Sl. No. 14- List of all the Doctors, consultants etc. as mentioned with name,
qualification, experience etc. full time or part time or contractual to be submitted along with
the application form.
6. For Sl. No. 15- If a particular license is not required in your region or is not applicable for
your set up kindly mention the same in “Remarks” column. You can also use this column to
state “applied for”; “pending approval”; “applied for renewal on….” etc. Kindly submit
scanned copies of all the statutory requirements while submitting the documents
The Clinic shall ensure that it shall send an updated application form to NABH in case of
any changes especially before assessment.
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DEFINITION OF CLINIC:
A standalone healthcare facility that provides allopathic services by Doctors registered with
Medical Council of India or State Medical Council.
The Clinic may be located in the community or in the premises of an organization, such as
school, factory, etc., and includes the following types of healthcare facilities:
Sl. No. Healthcare facility Definition
1. Clinic A standalone healthcare facility for services (other than OPD
of a hospital).
2. Polyclinic A Clinic which provides services in 2 or more specialties,
working in cooperation and sharing the same facilities
3. Dispensary A Clinic, which in addition to patient care, provides facilities
for dispensing medicines.
In addition a “clinic” may have add on services as follows:
Sl.no. Services
1. Diagnostic services • Laboratory
• Imaging
• Other
2. Therapeutic services such as: • Procedures
3. Support services such as: • Pharmacy
• Physiotherapy
• Nutrition
• Counseling etc.
In the Standards, the Dispensary/Polyclinic/ Clinic hereinafter will be referred to as “Clinic”
Exclusions:
1. Day-care Centers:
Day Care will include facilities that have admitting beds for treating patients, Other than for
overnight stay.
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The services may, in addition, include services, diagnostics and treatments such as ambulatory
surgical procedures, dialysis, chemotherapy etc.
These Standards are NOT APPLICABLE for non allopathic systems of medicine such as
Ayurvedic, AYUSH, homeopathic, wellness centers Alternative medicine streams etc.
1. Name of the clinic:
2. Address:
3. Ownership:
4. Year in which established:
5. Contact person (s):
(Please indicate with whom correspondence to be made)
Medical officer in-charge: (or equivalent)
A. Mr./Ms./Dr. ___________________________________________________________
Tel: _____________________________Mobile: _______________________
Fax: ___________________________________________________________
E-mail: ___________________________________________________________
B. Mr./Ms./Dr. ___________________________________________________________
Tel: _____________________________ Mobile: ______________________
Fax: ___________________________________________________________
E-mail: ___________________________________________________________
6. Is the Clinic registered with Local Authorities?
(Where applicable as per the State Norms, please give details of registration and authority)
________________________________________________________________________
7. Type of Clinic
Sl.no. Healthcare facility Yes/no
1. Clinic
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2. Polyclinic
3. Dispensary
8. OPD data:
(Clinic shall furnish data from three months upto two years, depending on the date of establishment)
Period Number of OPD Patients
9. Details of clinical services being provided by the clinic
Type of OPD Yes/no Remarks if any
General Practitioner /Family Physician YES/NO
Speciality Clinics
Dermatology YES/NO
General Medicine YES/NO
Geriatics YES/NO
Cardiology YES/NO
Ear, Nose, Throat (ENT) YES/NO
Endocrinology YES/NO
Gastroenterology YES/NO
Gynaecology and Obstetrics YES/NO
Hepatology YES/NO
Internal Medicine YES/NO
Immunology YES/NO
Nephrology YES/NO
Neurology YES/NO
Opthalmology YES/NO
Orthopaedics YES/NO
Oncology YES/NO
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Paediatrics YES/NO
Psychiatry YES/NO
Rheumatology YES/NO
Respiratory Medicine YES/NO
Other (please specify) YES/NO
10. Details of diagnostic / other Services if provided
Diagnostic Service In House Out sourced Remarks if any
Diagnostic Imaging:
X-Ray YES/NO YES/NO
Ultrasound YES/NO YES/NO
CT Scanning YES/NO YES/NO
Mammography YES/NO YES/NO
MRI YES/NO YES/NO
PET YES/NO YES/NO
Other, please specify
Pathology:
Sample Collection YES/NO YES/NO
Clinical bio-chemistry YES/NO YES/NO
Clinical immunology YES/NO YES/NO
Clinical microbiology YES/NO YES/NO
Clinical Pathology YES/NO YES/NO
Haematology YES/NO YES/NO
Histopathology YES/NO YES/NO
Others
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2D Echo
Audiometry
ECG
EEG
EMG
Pulmonary Function Tests
Tread Mill Testing
Any Other Diagnostic services
In House Out sourced Remarks if any
Medicine
Pharmacy YES/NO YES/NO
Allied Health Services In House Out sourced Remarks if any
Ambulance Service YES/NO YES/NO
...........
Counselling YES/NO
Dietetics YES/NO YES/NO
...........
Endoscopy YES/NO
Laser YES/NO .............
Nursing YES/NO YES/NO
Occupational Therapy YES/NO YES/NO
...........
Optometry YES/NO
Physiotherapy YES/NO YES/NO
...........
Procedures YES/NO
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Sedation YES/NO ...........
Social Services YES/NO YES/NO
Speech and Language
YES/NO YES/NO
Therapy
YES/NO ...........
Vaccinations
Other, please specify YES/NO YES/NO
13. Non clinical and Administrative Departments, if applicable
Support service In House Out sourced Remarks
Cleaning services YES/NO YES/NO
Management of clinical waste YES/NO YES/NO
Management of non-clinical
YES/NO YES/NO
waste
Security YES/NO YES/NO
Other, please specify YES/NO YES/NO
14. Staff Information (List all i.e. full time, part and contractual)
Group Number Remarks if any
Managerial
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Doctors:
Consultants (Full Time)
Consultants(Visiting)
Resident Doctors
Nurses
Technicians
Paramedical
Others
15. Furnish details of applicable Statutory/ Regulatory requirements the clinic is governed
by*:
License/Certificate Number and Date Valid Upto Remarks (if any)
General:
Bio-medical Waste
Management and Handling
Authorization
Employee Provident Fund
Employee State Insurance
PAN
Registration Under Clinical
Establishment Act (or similar)
Registration With Local
Authorities (specify authority)
Facility management:
Fire (NOC)
License for Diesel Storage
License for Electrical
Installations
License to Store Compressed
Gas
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Registration for Boiler
Sanction for Lifts
Radiology:
X-ray (including portable and
cath lab)
CT Scan Machine
License for Nuclear Medicine
PNDT Act Registration
Clinical departments:
Blood bank
License for MTP
Pharmacy (if over multiple locations license for each of them separately)
Drugs-Bulk license
Drugs-Retail license
Narcotic license
Miscellaneous:
Canteen/ F & B license
License for Possession of
Rectified Spirit and ENA
Any other:
*Please submit scanned copies of all the statutory requirements while submitting the documents
16. Litigation, if any:__________________________________________________________
17. Date of Last Self assessment:__________________________________________
18. Date Application Completed: _________ Day _______ Month ___________ Year
19. Terms and Conditions for maintaining NABH Accreditation submitted:
Yes No
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Authorised Signatory:________________________
Name: ____________________
Designation:_____________________
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National Accreditation Board for Hospitals & Healthcare Providers
C/o Quality Council of India 2nd Floor, Institution of Engineers Building,
Bahadur Shah Zafar Marg, New Delhi 110 002 ( India )
Telefax: +91-11-2337 9321 / 23379621
E-mail: zainab. nabh@qcin.org, Website: www.qcin.org
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