Page 1 of 2 - Employees' State Insurance · and the application fee of Rs. 300/- (non-refundable) be submitted with duly filled in Expression of Interest (E.O.I) form by way of Demand

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REGIONAL OFFICE, EMPLYOYEES STATE INSURANCE CORPORATION

{MINISTRY OF LABOUR & EMPLOYMENT, GOVT. OF INDIA} PANCHDEEP BHAWAN, J.L. NEHRU MARG, PATNA-800001

Phone/ Fax: -0612-2530047; Email: [email protected] www.esicbihar.in

No. 42-F-16/15/2011/Medical/Tie-up/IMP/ Dated: 15.05.2018

EXPRESSION OF INTEREST (EOI) FOR

1. Empanelment Of Panel Doctor (IMP) Under ESI Scheme In Bihar For Primary Medical Care. (In The Area Given In Table A & B Below.)

2. Empanelment Of Hospitals/ Nursing Homes/ Clinics/ Diagnostics Centers/ Radiology Centre For Providing Secondary/ Super Specialty Treatment/ Dental Treatment/ Diagnostics (Pathology, Radiology, etc.) to Insured Persons & their eligible Dependants at CGHS/ AIIMS/ ESIC Rate

Expression of Interests (EOI) is invited from Private Registered Medical Practitioners/

Doctors (Minimum MBBS) or Clinics/ Nursing Homes run by such doctors for empanelment as Insurance Medical Practitioner (IMP)/ Panel Doctor for providing primary health services and basic investigation and from reputed Private/ Corporate Hospitals & Nursing Homes for Secondary/ Super Specialty Treatment/ Dental Treatment/ Diagnostics (Pathology, Radiology, etc.), under ESI Scheme, to Insured Persons (IP) and their eligible families living in the following areas given in Table A & B below:-

A. Municipal limits of the following specified District Headquarters of Bihar: -

S N District Head Qrts S N District Head Qrts S N District Head Qrts 1 Aurangabad 9 Kaimur 17 Saharsa 2 Araria 10 Khagaria 18 Shekhpura 3 Arwal 11 Kishanganj 19 Sheohar 4 Banka 12 Lakhisarai 20 Siwan 5 East Champaran 13 Madhepura 21 Supaul 6 Gopalganj 14 Madhubani 22 West Champaran 7 Jamui 15 Nawada 8 Jehanabad 16 Purnia

B. And also in the following places of following Districts where ESI Act is implemented in the entire area of Districts:-

mailto:[email protected]

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SN District Places/ Blocks S

N District Places/ Blocks

1 Darbhanga Darbhanga 9 Munger Munger/ Jamalpur

2 Begusarai Bagusarai/ Barauni 10 Nalanda Rajgir

3 Bhagalpur Bhagalpur/ Kahalgaon 11 Patna Patna (Except IMP & Dental) Barh/ Bihta/ Fatuha/ Daniyawana

4 Bhojpur Arrah 12 Rohtas Dehri/ Banjari/ Sasaram

5 Buxar Buxar, Dumraon 13 Samastipur Samastipur

6 Gaya Gaya/ Bodhgaya 14 Saran Chhapra/ Marhaura

7 Katihar Katihar 15 Sitamarhi Sitmarhi

8 Mujaffarpur Mujaffarpur/ Kanti 16 Vaishali Hajipur, Vaishali

Interested Doctors (minimum MBBS) desirous of working as contractual Panel Doctor and Hospitals, Nursing Homes and Clinics desirous of providing Super Specialty/ Secondary Medical Care, Dental Treatment and Tests/ Diagnostics facilities in the above areas may download Application Form from our website www.esicbihar.in/ www.esic.nic.in and apply if they agree to terms and conditions therein, and submit EOI as per following schedule:-

E O I for Availability of EOI Form by

hand in Office.

Last Date & Time of submission of Duly filled EOI

document

Date & Time of Opening of EOI

Place of submission of EOI forms/

Opening of E O I

Panel Doctor (IMP) for

Primary Care

18/06/2018 5:00 pm.

19/06/2018 2:00 pm 19/06/2018 3:00 pm

ESIC, Panchdeep Bhawan, Income Tax Golamber, J L Nehru Marg Patna 800001 Hospital

25/06/2018 5:00 pm. 26/06/2018 2:00 pm

26/06/2018 3:00 pm

However All Please Note That Doctors Or Hospitals May Apply For Primary (Panel Doctor) Secondary/ Super Specialty Treatment/ Diagnostics (Pathology/ Radiology etc) Even After The Last Date But Their EOI Would Be Examined & Decided As & When There Is Any Need For The Same.

If the EOI opening day is declared holiday, it will be opened on next working day at the same time. The Regional Director, ESIC, Bihar reserves all rights to reject one or all the applications without assigning any reason thereof.

Further Details may be seen on the website www.esicbihar.in/ www.esic.nic.in

Additional Commissioner & Regional Director

ESIC. BIHAR REGION, PATNA

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Signature, Name & Stamp of the Doctor

REGIONAL OFFICE, EMPLYOYEES STATE INSURANCE CORPORATION

{MINISTRY OF LABOUR & EMPLOYMENT, GOVT. OF INDIA} PANCHDEEP BHAWAN, J.L. NEHRU MARG, PATNA-800001

Phone/ Fax: -0612-2530047; Email: [email protected] www.esicbihar.in No. 42-F-16/15/2011/Medical/Tie-up/IMP/ Dated: 15.05.2018

EXPRESSION OF INTEREST (EOI) FOR

1. Empanelment Of Panel Doctor (Imp) Under ESI Scheme In Bihar For Primary Medical Care. (In The Area Given In Table A & B Below.)

2. Empanelment Of Hospitals/ Nursing Homes/ Clinics/ Diagnostics Centers/ Radiology Centre For Providing Secondary/ Super Specialty Treatment/ Dental Treatment/ Diagnostics (Pathology, Radiology, etc.) to Insured Persons & Their Dependants at CGHS/ AIIMS/ ESIC Rate.

Expression of Interests (EOI) is invited from Private Registered Medical Practitioners/

Doctors (Minimum Modern Medicine/ MBBS) or Clinics/Nursing Homes run by such doctors for empanelment as Insurance Medical Practitioner (IMP)/ Panel Doctor for providing primary health services and basic investigation and from reputed Private/ Corporate Hospitals & Nursing Homes for Secondary/ Super Specialty Treatment/ Dental Treatment/ Diagnostics (Pathology, Radiology, etc.), under ESI Scheme, to Insured Persons (IP) and their families living in the following areas given in Table A & B below:-

A. Municipal limits of the following specified District Headquarters of Bihar: -

S N District Head Qrts S N District Head Qrts S N District Head Qrts 1 Aurangabad 9 Kaimur 17 Saharsa 2 Araria 10 Khagaria 18 Shekhpura 3 Arwal 11 Kishanganj 19 Sheohar 4 Banka 12 Lakhisarai 20 Siwan 5 East Champaran 13 Madhepura 21 Supaul 6 Gopalganj 14 Madhubani 22 West Champaran 7 Jamui 15 Nawada 8 Jehanabad 16 Purnia

mailto:[email protected]

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B. And also in the following places of following Districts where ESI Act is implemented in the entire area of Districts:-

SN District Places/ Blocks S

N District Places/ Blocks

1 Darbhanga Darbhanga 9 Munger Munger/ Jamalpur

2 Begusarai Bagusarai/ Barauni 10 Nalanda Rajgir

3 Bhagalpur Bhagalpur/ Kahalgaon 11 Patna Patna (Except IMP & Dental) Barh/ Bihta/ Fatuha/ Daniyawana

4 Bhojpur Arrah 12 Rohtas Dehri/ Banjari/ Sasaram

5 Buxar Buxar, Dumraon 13 Samastipur Samastipur

6 Gaya Gaya/ Bodhgaya 14 Saran Chhapra/ Marhaura

7 Katihar Katihar 15 Sitamarhi Sitmarhi

8 Mujaffarpur Mujaffarpur/ Kanti 16 Vaishali Hajipur, Vaishali

1. In the above 22 District Headquarters given in Table A above & required Places given in 16 Districts of Table B above, Doctors/ Institutions will be appointed on panel on contractual basis as Insurance Medical Practitioner (IMP) and institutions or doctors (at least MBBS) have to apply for those District Headquarters & Places where their clinics (or nursing homes/ hospitals etc) are situated.

Appointed IMP doctors or Institutions will be paid a fixed capitation fee of Rs.300/- per Insured Person (Employee) family unit per annum (maximum allotment of 2000 family units per doctor, that is upto Rs. 50,000/- per month), along with other remuneration, as per rule on pro rata basis per month, for Primary Medical Care.

Those Clinics/ Nursing Homes/ Hospital can also apply for empanelment as Panel Doctor (IMP) for Secondary Medical Care also; but such Nursing Home/ Hospital shall have to choose either empanelment as panel Doctor (IMP) for Primary Medical Care/ Out Door Treatment or Panel Hospital/ Nursing Home for Secondary Medical Care/ Indoor Treatment under ESI Act, due to probable conflict of interest as the IMPs are also to refer patients for Secondary Medical Care.

2. Empanelled Hospitals/ Nursing Homes/ Clinics/ Diagnostics Centers/ Radiology Centre For

Providing Secondary/ Super Specialty Treatment/ Diagnostics (Pathology, Radiology, etc.) will be paid at CGHS/ AIIMS/ ESIC rate.

The Application Form may be downloaded from the website www.esicbihar.in or www.esic.nic.in and the application fee of Rs. 300/- (non-refundable) be submitted with duly filled in Expression of Interest (E.O.I) form by way of Demand Draft/ Bankers Cheque in favour of ESI Fund A/C No. 2 payable at Patna.

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The duly filled in documents must be submitted in Sealed Envelope super scribed on Top of

the Envelope as “EOI for IMP for Place……………” or

“EOI for Sec./ SST/ Dental/ Diag. for Place……………” (as the case may be) in the

separate Box placed for the purpose, in the Regional Office, ESI Corporation, Panchdeep Bhawan, J.L. Nehru Marg, Patna – 800001.

Schedule of EOI:-

E O I for Availability of EOI Form by

hand in Office.

Last Date & Time of submission of Duly filled EOI

document

Date & Time of Opening of EOI

Place of submission of EOI forms/

Opening of E O I

Panel Doctor (IMP) for

Primary Care

18/06/2018 5:00 pm.

19/06/2018 2:00 pm 19/06/2018 3:00 pm

ESIC, Panchdeep Bhawan, Income Tax Golamber, J L Nehru Marg Patna 800001 Hospital

25/06/2018 5:00 pm. 26/06/2018 2:00 pm

26/06/2018 3:00 pm

However All Please Note That Doctors Or Hospitals May Apply For Primary (Panel Doctor) Secondary/ Super Specialty Treatment/ Diagnostics (Pathology/ Radiology etc) Even After The Last Date But Their EOI Would Be Examined & Decided As & When There Is Any Need For The Same.

If opening date happens to be a holiday, it will be opened on next working day at the same time. The Regional Director, ESIC, Bihar reserves all rights to reject one or all the applications without assigning any reason thereof.

Further Details may be seen on the website www.esicbihar.in/ www.esic.nic.in

Additional Commissioner & Regional Director ESIC. BIHAR REGION, PATNA

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Annexure-I UNDERTAKING

(To Be Printed on Letter Head of the Doctor/ Bidder) To

The Regional Director, ESI Corporation, (Ministry of Labour & Employment, Govt. of India) Panchdeep Bhawan, J.L. Nehru Marg, PATNA-800001

Subject: Expression of Interest (EOI) for providing services as Insurance Medical Practitioner (IMP). Sir,

In response to your advertisement on the subject mentioned above, I am submitting sealed EOI/ Response for providing services as Insurance Medical Officer (IMP) Doctor at ______________________ (Name of the Place, __________________Name of the Block _________________________(Name of the District)

Application Fee of Rs.300/ -in the form of Demand Draft No. ____________ dated _______________(favoring “ESI Fund A/c No. 2, payable at Patna) is also enclosed. I have carefully gone through and understood the contents of the terms and conditions of the EOI Document and I shall abide by all the terms and conditions set forth in the Tender Document.

Yours Faithfully, Encl. As above.

(SIGNATURE)

Name of Doctor and Stamp of Doctor/ Clinic/ Doctor Nursing Home

Name of

Address:

PIN Code Mob/ Landline No. Email ID Website Address Bank A/C No. Name of the Bank IFSC Code MICR No.

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TERMS & CONDITIONS 1. SELECTION OF IMP: After invitation of application through open process the REGIONAL DIRECTOR, ESIC (BIHAR), would prepare a panel of IMPs based on the recommendations of Allocation Committee constituted for the purpose. The maximum number of IP family units on the Panel of IMP is at present restricted to a maximum of 2000. IMP Doctor will be paid a fixed capitation fee of Rs. 300/- per IP family unit per annum, which includes primary health services, cost of engaging support staff, for investigation facilities of Hemoglobin, Blood Sugar and Urine (albumin & sugar) and essential medicine(s) required to be dispensed on spot. 2. The IMP would be included in the Panel for contractual engagement after fulfilling the

following conditions: Eligibility: (a) Minimum qualification: MBBS. (b) Should be registered with the State Medical Council/ Medical Council of India or as applicable. (c) Should be less than 67 years at entry time and should not exceed 70 years for continuation. (d) Should have minimum experience of 2 years in general practice in a clinic/ hospital or both after obtaining the medical degree. (e) Must be medically fit as certified by Medical Officer of ESI Hospital/ Dispensary /Designated Hospital/ Tie-up Hospital/ Civil Surgeon. 3. Infrastructure requirement in IMP/ Clinic: The clinic should have the following: (a) Space for waiting, (b) Consultation cum Examination room, (c) Dispensing room, (d) Facility for basic investigations like Hemoglobin, Blood Sugar and Urine: sugar & albumin, (e) Toilet, (f) There should be clear title regarding tenancy or ownership of the premises, i.e. rent agreement issued in the name of the applicant/ institution or some other document(s) to prove the legal occupancy of the clinic, (g) The IMP Doctor must have a computer / laptop/ tab / smart phone with internet facility so that IMP Doctor is able to verify eligibility of the beneficiaries online for extending treatment to the attached IP/beneficiary, (h) The IMP Doctor must have the minimum prescribed surgical and medical equipment required on day to day basis for medical practice as detailed in enclosed Annexure, (i) The IMP Doctor must have a minimum of two contact numbers, one of which must be a mobile phone number. 4. TENURE: Contract period of IMP Doctor shall be for one year, renewable every year on satisfactory services, for a maximum period of three years. In exceptional cases, this may be extended to five years. (a) Maximum age of IMP Doctor will be 70 years, subject to medical fitness. (b) The performance of the IMP shall be monitored by the Local Committee constituted under Regulation 10(A) of ESI (General) Regulation periodically. The ESIC Local Committee shall submit its report to the State Executive Committee / Designated Authority. The renewal of the tenure shall be decided on the basis of these reports. The ESIC Local Committee may also make surprise inspections at any reasonable time to check: (I) The condition and infrastructure of the clinic. (II) Whether records are being maintained properly. (III) Whether medicines are being dispensed in accordance with the prescribed norms/instructions. (IV) Whether returns are being sent as prescribed.

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5. TERMS OF SERVICE: An IMP will provide treatment to: (a) All eligible insured persons (IP) and their dependent family members allocated to him, (b) Any insured person or his dependent that needs treatment in case of an accident or any other emergency.

6. DUTIES AND FUNCTIONS: Working hours: Total no of working hours: 7 hours (a) The clinic must be open for a minimum 3 hours in the morning, starting not earlier than 8.00AM and not later than 9.00AM and 3 hours in the evening, starting not earlier than 5.00PM and not later than 6.00PM. (b) The clinic timings will be intimated to Regional Director, ESIC. (c) The clinic hours must be displayed prominently in an appropriate place in the clinic. (d) An IMP Doctor is required to provide treatment to his patients to the extent that is generally given by a General Medical Practitioner. (e) He shall render whatever services as possible in the interest of the beneficiary in case of an emergency, including difficult/complicated maternity cases. (f) He shall keep / provide essential medicines in the clinic as per list provided by the Corporation/ESIS detailed in Annexure-V. (g) In case the illness/ condition of the patient is such that it requires treatment that is not within the obligations/ capacity of the IMP, he may inform the patient and refer him to the nearest ESI Dispensary/ Hospital, ESI Tie-Up Hospitals/ recognized Hospital or Govt. hospital. If IMP Doctor arranges for the patient’s transfer by ambulance or otherwise and any expenses incurred by him on the transport, the same shall be reimbursed to him by the REGIONAL DIRECTOR, ESIC, Bihar. (h) He shall issue Medical Certificates, free of charge, as reasonably required for sickness, maternity, employment injury and death etc. as under regulations or as may be required from time to time by the ESI Corporation . (i) IMP Doctor should maintain monthly record of allotted patients, patients visit, distribution of medicine, stock register etc. of medicines supplied under ESI Scheme, if any, that are required to be maintained and send monthly reports to the concerned Authorities as per Annexure-VI, VII & VIII. Visit Register is to be maintained as per Annexure-VI. Record of distribution of medicine is to be maintained as per Annexure-VII. Stock Register is to be maintained as per Annexure-VIII. (a) He shall furnish returns, such as statistics, drug requirement, Certificate Book etc. in such forms as prescribed by Corporation or the State Government or Director ESI Scheme/AMO in Annexure- VII & VIII (b) He shall accept ESIC E Pehchan Card (with Aadhar Card or Govt. issued ID card), ESIC 86, TIC, ESIC-37, 105, 166, 48 etc. as prescribed by the Corporation (which are eligibility forms of various types), for identification and treatment to eligible beneficiary. (c) He shall refer beneficiaries who require consultation with Medical Referee (MR)/ Doctor of ESIC. (d) He shall afford access to the ESIC Doctor/ MR/ MVO at all reasonable times to his clinic where the records required by these terms of service are kept for the purpose of inspection of such records and to furnish to the ESIC Doctor/ MR/ MVO such records or necessary information with regard to any entry therein, as he may request. (e) IMP Doctor shall meet the MR at the request of MR, as may be reasonably required in connection with duties and responsibilities of the IMP doctor. (f) He shall answer i, if needed, within a reasonable period as specified by the MR, any query raised by the MR in regard to prescription or certificate issued by the IMP or any statement made in any report furnished by him under these terms of service.

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(g) He shall answer in writing, if needed, within a reasonable period as specified by the MR, any query/clinical information regarding any IP to whom the IMP has declined a Medical Certificate. (h) He shall sign/ countersign Medical Reimbursement Claims/Bills of the Insured Employees (IPs). (i) He shall give application to ESIC for registration with UTI- ITSL for online referral of ESI beneficiary to an ESIC Tie- up Hospital for Secondary/ Super Speciality treatment or diagnostic tests, as may be required. 7. PROCEDURE FOR DISBURSEMENT OF DRUGS:

(a) The essential drugs that are prescribed by the Corporation are to be collected from the nearest ESI Dispensary/ store designated for this purpose by ESIS/ ESIC. (b) The medicines need to be collected from the designated dispensary/ store through monthly indent/as and when required after prior assessment and intimation regarding requirement as per prescribed format. The State Govt./ ESIC shall issue one indent book to each IMP and record of the same shall be maintained by the State Govt./ ESIC so that the audit of the stock can be performed by the State Govt. (c) Drugs are to be dispensed for not more than 7 days at a time. (d) IMP Doctor will also have to keep / give some emergency medicines to the attached beneficiaries. 8. MONITORING:

(a) The ESIC Local Committee constituted under Regulation 10 A of the ESI (General) Regulation would monitor functioning of IMPs by carrying out surprise inspection of IMPs. The Local Committee shall inspect mainly the following functions: - (I) Whether records are being maintained properly. (II) Whether medicines are being dispensed in accordance with the prescribed Norms/ instructions. (III) Whether the necessary information have been displayed prominently on the Notice board. (IV) Annually review performance of the IMP Doctor and the report of the same shall be submitted to State Executive Committee / Appropriate Authority. If the IMP Doctor is continuing for more than 3 years, then the Local Committee will need to review the entire system in the area and make its recommendations for further action to the State Executive Committee / Appropriate Authority. Contents of Notice Board Annexure-X. 9. REMUNERATION: Each IMP Doctor will be allowed to enroll up to 2000 Insured Person(IP) families with a package remuneration @ of Rs. 300/- per IP family per annum, which will include providing of primary health services to IP and his family, distribution of drugs, issuance of medical certificate and investigation facility for Urine (albumin and sugar), Hemoglobin, and blood sugar. An additional amount of Rs.10,000/- per year shall be provided to the IMP in two installments payment for the month of June and December for the maintenance of the Computer System/ Laptop/ Tab/ Smartphone with Internet facility for online verification of entitlement of the beneficiary for treatment. The IMP Doctor shall supply specified medicines to IPs and family members collected by him from ESIS Dispensary/ designated stores. The facility available, including Investigations and medicines, should be displayed on a notice board. An IMP Doctor will not demand or accept any fee or remuneration from any insured person / beneficiary.

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10. PROCESS OF PAYMENT: Payment to IMP Doctor shall be made on monthly basis (for full month or part thereof as the case may be, on pro-rata basis) on the fixed rate based on number of IPs attached with IMP Doctor as on 7th of each month or the average number of IPs attached with that IMP as per Dhanwantri / certification of Branch Manager, ESIC on the basis of allocations. 11. Insured Person /Employee and IMP Doctor: - (a) An IP will be free to get registered with any IMP Doctor of his/ her choice but will not visit any other IMP Doctor. IP will have the option to change IMP Doctor in case of change of residence or if he finds the services of existing IMP Doctor not to his/ her satisfaction. Meanwhile he will be free to visit any of the services dispensaries for treatment etc. When an IP wishes to change his IMP on account of (a) change of residence or (b) after one year in the list of the IMP or (c) otherwise, he should inform his employer/ Branch Manager, ESIC for reallocation of IMP. The employer/ Branch Manager shall submit the request of IP through ERP portal by following the same process as was followed during the initial allotment of IMP Doctor or the Branch Manager shall make such reallocation as per extant instructions. (b) An IMP Doctor may remove the name of an insured person (IP) or any family member from his list, subject to such conditions as imposed by the Allocation Committee, after informing Appropriate Authority, giving proper reason for removing the name. The removal of such a person shall commence after one month of such information being submitted to the Director ESIS / Appropriate Authority, or Branch Manager. Branch Manager will inform his/ her employer for attachment of IP to another IMP Doctor / Dispensary. (c) If the IMP Doctor cannot for some reason make himself available to attend his dispensary /clinic, he shall make alternate arrangement for securing the treatment of insured persons (IP) and their family attached to him in his clinic. He shall inform through e-mail & over phone MR / Branch Office of ESIC of the proposed absence and arrangement made thereof for the treatment of IPs and their families. An IMP Doctor shall not absent himself for more than one week without first informing / Appropriate Authority, of his proposed absence and of the Doctor responsible for conducting his duty during his absence. Appropriate Authority may grant leave of absence up to 2 months to IMP. (d) When an IMP Doctor is unable to provide treatment to ESI beneficiaries for an extended period or due to a disability, he must give one month notice about the duration to Appropriate Authority, about his inability. (e) The IMP shall be liable for any compensation for injury or damage suffered by an insured person (IP) or his family as a result of negligence on his part. 12. ACCEPTANCE OF IP BY IMP Doctor; PROCEDURE FOR TAKING TREATMENT: - Insured persons (IP) are provided the following documents through their employers/ ESIC. (a) Medical Acceptance Card (MAC) (ESIC Med 7-B)/ E- Pehchan Card with Aadhar/ Govt. issued

ID Card. (b) Temporary Identification Certificate (TIC) while filling up of the registration form for registration of IP on IP portal, the employer shall seek the consent of IP for attachment to a particular IMP Doctor / Dispensary. The names of IMP shall appear on IP portal indicating the names of IMP and the

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number of IPs enrolled with him/her. Based on the number of IPs already enrolled with the particular IMP Doctor, the IP shall be allotted particular IM. Before submitting the IP form for online registration, IP has to get registered on ESIC portal for availing of the benefits of ESI Scheme and his eligibility would be counted from the date of registration on the IP Portal. Benefit of IP will start only after registration of IP on ESIC portal. 13. DISPUTES BETWEEN IP AND IMP Doctor: -

(a) In case of a dispute between the IMP Doctor and his patient, the terms of service are contained in rules 17 and 21 of the ESI Medical Benefit Act, 1953. The dispute will be investigated by competent authority and action that may be taken by the Regional Director will include the withholding of remuneration of the IMP Doctor, especially where there has been a breach of service by IMP Doctor or removal of IP from IMP Doctor list in case it is found that IP was at fault. (b) When ESIC or the Director or the AMO or any other authorized person wants to serve any notice to an IMP, it shall be delivered either by email, personally or by post to him to the address that he has last notified to the ESIC as being his place of residence. In case of disciplinary action or damages the letter shall be sent by Registered Post. (c) An IMP is required to allow access to his clinic to any person/s authorized by the ESIC or the State Govt. at a reasonable time for inspection of the same and also to inspect the records as required. He is also required to furnish these records and to answer any query/give information with regard to any entry therein, as and when required. (d) He is required to answer any inquiries of any person authorized by the State Govt./ESIC with regard to any prescription or certificate issued by the IMP or any statement made in any report furnished by him as per these terms of service. 14. TERMINATION/WITHDRAWL OF SERVICES OF IMP (a) ESIC/ Director, ESIS Medical Services/ Appropriate Authority, can suspend or terminate the agreement with an IMP and delete his name from the Medical List after giving due notice of not less than one month, when: (I) Patients are not satisfied with his treatment/conduct (II) If he overprescribes. (III) If there is lax Certification. (IV) If he is not maintaining records as per requirement or not sending reports as required. (V) Or for any other reason deemed necessary by ESIC/ Director/ Appropriate Authority. Local Committee after investigating the matter shall recommend for termination/ withdrawal/ continuation of services and the same shall be submitted to State Executive Committee/ Appropriate Authority, for further action. The ESIC/ Appropriate Authority shall be at liberty to suspend the panel system as a whole if the system does not function properly and efficiently. The ESIC/ Appropriate Authority shall then give three months notice to each IMP Doctor of the date from which the suspension is to take place. Simultaneously the State Govt./ Appropriate Authority shall make suitable alternative arrangement for providing medical services. (b) An IMP is entitled at any time to give notice to ESIC/ the Director/ Appropriate Authority, if he desires to cease to be an IMP. His name shall be deleted from the Medical List at the end of three months from the date of receipt of his application, or shorter, at the discretion of the Director, ESIS Medical Services / Appropriate Authority. Till such time he shall continue to give service as before.

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15. RECORD KEEPING AND REPORTING: -

The following records are to be maintained by the IMP Doctors in the prescribed format and the same may be sent to DIMS / Appropriate Authority, with a copy to Regional Director. If the report is not sent regularly for three months, IMP would be issued a notice. If the report is not received for another three months, the payment to IMP will be stopped and inspection will be done by a team constituted by the Chairman, State Executive Committee / Appropriate Authority, which shall recommend further action. 16. COMPLAINT REGISTER: -

The IMP Doctor shall maintain a complaint register of the size of about 8” x 14”

containing about 40 pages having hard cover on both sides. The cover page shall have the title as under: -

“COMPLAINT REGISTER”.

(I) Name of IMP Doctor: ----------------------- (II) Address of IMP Clinic: ------------------------

Certified that the register contains ___ numbers of pages. All the pages have been numbered.

Signature and stamp issuing authority

(The register will be maintained and kept at a prominent place in the clinic. The register can be inspected by Medical Referee/Director of State/ Branch Office Manager/Member of Local committee/ Regional Director and member of State Executive Committee/ Appropriate Authority. This register will also be an important document to consider extension or otherwise of the services of IMP.) Note: The reporting formats will be submitted online as soon as the necessary software becomes available.

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16. List of Annexure:

I. Application For Providing Insurance Medical Practioner To Be Returned, Duly Completed On The Letterhead Of The Applicant..

II. Format Of Application For Use Of Candidates For IMP. III. Medical Fitness Certificate for Imp. IV. Minimum List of Medical and Surgical Equipment to be maintained by an Insurance

Medical Practitioner. (With Remarks ‘Yes’ or ‘No’ as the case may be). V. Indicative list of medicines required to be available with the IMP doctor. VI. Visit Register. VII. Record Of Distribution Of Medicines To Individuals Patient. VIII. Monthly Proforma for record of Medicines (STOCK REGISTER). IX. Agreement Proforma. X. Sign Board Should Be 5ft Long And 3ft Wide Notice Board I.M.P.

Clinic For Esi Beneficiaries. XI. Quarterly Assessment Of Performance Of IMP

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Annexure-II

FORMAT OF APPLICATION FOR USE OF CANDIDATES FOR INCLUSION IN MEDICAL LIST AS INSURANCE MEDICAL PRACTITIONER DOCTOR UNDER THE EMPLOYEES’ STATE INSURANCE SCHEME

1. Name in full (in block letters) _____________________________________________ 2. Date of Birth____________________________________________ 3. Sex___________ 4. Name of spouse if married _________________________ 5. Next of kin/Nominee_____________________________________________ 6. Medical qualification and other post graduate qualification: - University /Examination Particulars Date of Examination Board of Qualification

7. (a) MCI/State Medical Council registration no:_________________________ 8. Full residential address ___________________________________________________ __________________________________________ _________ ___________________________________________________ 9. Email Id:__________________________ Phone nos. _______________ _____________________________________ 10. Full address of Clinic

___________________________________________________________ _________________________________________________________ 11. Distance between notified area and clinic ___________________________________ 12. Date from which practicing in the locality_____________________________________ 13. Accommodation in Clinic _____________________________________________

Room Area in Sq.ft. Function

14. Do you have: - (1) A separate Consultation Room? (2) Space where patients can wait? (3) Your own dispensing arrangements? (4) A lab facility? (5) A toilet (6) A computer / laptop /tab with or without internet facility?

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15. Clinic Timings_____________________

16. Availability of ancillary staff in Dispensary/Clinic?

Designation Full Time Part Time

17. Have you ever been debarred/ penalized by the MCI/State Medical Council?

18. If selected on the Medical List, how many insured persons are you prepared to have on your

list (Max: 2000) 19. Status of clinic (please tick) 1. Self owned 2. Rented

(Enclose copy of deed as proof)

20. State equipment and appliances maintained in your dispensary as per attached list. 21. Experience as General Medical Practitioner* :

Period Address of the Clinic From To

** The applicant should have at least experience of 2 years as general practitioner.

22. Whether you were previously an IMP under ESI Scheme? If so, please state Code no. and reason for withdrawal of name from Medical List.

23. Have you applied previously? If so, what date, month and year?

(a) Registration Certificate (b) Diploma or Degree certificate (c) SSC/School leaving certificate showing date of birth (d) Proof of documents showing ownership/tenancy of the clinic. (Ownership papers, rent receipt, rent agreement, electricity bill and water connection bill.) (e) All copies of above documents are to be self attested before submission.

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DECLARATION

I,__________________________________, a candidate for inclusion in the Medical List as an Insurance Medical Practitioner under the Employees’ State Insurance Scheme declare that the particulars given above are true and correct to the best of my knowledge and belief. I have read and understood the terms & conditions of service and agree to abide by them if included in the Medical List.

Signature

Date: Place:

FOR OFFICIAL USE: - Recommendation of the allocation Committee: - Chairman (Allocation Committee) Approval of the Competent Authority, ESI Scheme Competent Authority ESI Scheme

Page 15 of 22


Annexure-III

MEDICAL FITNESS CERTIFICATE FOR IMP

(To be issued by IMO, ESI Dispensary/Hospital /Designated Hospital) Certified that I have examined Mr./Ms. --------------------------------- S/o/ D/o/ W/o ----------------- and found him/ her medically fit for the assignment of Insurance Medical Practitioner under ESI Scheme. His/ her age as per the documents is -----------------years and physically appears --------years of age. The signature of Doctor --------------- is attested below -------------------- Signature of IMP: Signature of IMP attested By IMO. Date:

Dated Signature of IMO / Doctor Along with stamp

Page 16 of 22


Annexure- IV

Minimum List of Medical and Surgical Equipment to be maintained by an Insurance Medical

Practitioner.

The clinic should have the following:-

1. Instruments for dressing of wounds.

2. Instruments for suturing of simple wounds

3. Instruments for incision and drainage of abscess.

4. Splints of various sizes.

5. Basic clinical examination equipment

6. Lab. Inv. Facilities .

Please indicate availability/ non availability of following items:-

Sl. No. Article Name of the Article

Availability Yes/ No

1 Bandages assorted

2 Dressing drum

3 Foley’s Catheter

4 1-0 Sterilized Silk Suture

5 Kramer wire of Gooej Splint

6 Artery Forceps 5”/ 6 “

7 Plain forceps

8 Forceps Sinus

9 Forceps Sterilizer, Cheatles

10 Plain forceps

11 Nasal Speculum No.2

12 Paper Adhesive Tape 1”

13 Plaster adhesive 3”x10 yds

14 Reflex hammer

15 Weighing machine

16 Scalpel

17 Scissors

18 Scissors, straight curved

19 Sheeting, Water proof 1 R

20 POP Bandage

21 Spatula

22 BP Apparatus

23 Spud, eye

24 Sterilizer portable

25 Stethoscope

26 BP Instrument

Page 17 of 22


27 Syringes 2 cc, 5 cc & 10 cc

28 Tape Measure

29 Test Tubes

30 Test Tube Holder

31 Test Tube stand

32 Distant Vision chart

33 Near vision testing set

34 Thermometer, clinical

35 Tongue depressor

36 Tray SS Instrument

37 Tray SS Kidney shaped

38 Wool, Cotton

39 Uristix

40 Glucometer with strips


Page 18 of 22


Annexure V

Indicative list of medicines required to be available with the IMP 1. Tab Paracetemol 500mg 2. Tab Chlorphenaramine Maleate, 25/50 3. Tab Ibuprofen 200/400 MG 4. Tab Declofinac sodium 50 MG 5. Tab Declofinac SR 100 MG 6. Tab Aspirin75/150/325mg 7. Declofinac Gel 8. Tab Ranitidine 150 MG 9. Tab Pantoprazole 40 MG 10. Tab Domeperidone 11. Tab Prochlorperazine 12. Tab Norfloxacin 400mg 13. Tab Metronidazole 200/400 14. Tab Loperamide 15. Tab Meftalspas 16. Tab Buscopan(Hyoscine Butylbromide) 17. Tab Cetrizine 10 MG 18. Tab Pheniramine maleate 25 MG 19. Syrup Digene 20. Tab Deriphyllin retard 150/300 21. Tab Deriphilline 22. Tab Unicontin (SR Theophylline) 23. Tab Albendazol 24. Sup Pyrantelpalmoate

25. Cough Syrup 26. Syp. Paracetemaol 27. Tab Co-trimoxazole 28. Syp Co-trimodazole 29. Tab Ciprofloxacin 250/500 MG 30. Cap Doxicycline 31. Cap Gynae CVP 32. Tab Tranexamic acid 250/500mg 33. Tab Duvadilan (Isoxsuprine) 34. Tab Methergin ()Methylergonovine) 35. Soframicin Cream 36. Silver Sulfadiazine (2%) Ointment 37. Betadine Ointment (Povidone Iodine) 38. Betadine lotion 39. Savlon lotion 40. Gammexene lotion 41. Capsule Amoxycillin 250/500 mg 42. Syr Amoxycillin 43. Tab Augmentin 625 44. Syr Augmentin 45. Tab Perinorm (Metoclopramide) 5/10mg 46. Tablet Domstal (Domperidone)10mg 47. Tab Emset (ondansetron)4/8mg


s

Page 19 of 22


Annexure-IX

AGREEMENT

This agreement made on ____________between Dr. ______________________S/o, D/o, W/o ________________________, Resident of ____________________________ On the one part, hereinafter called first party and the _______________ ESIC __________ ____ _____ through the Regional Director (Bihar) called the other part, called the second party. Whereas Dr. ____________________ has been engaged as Insurance Medical Practitioner (IMP) Doctor in ________________________________ on purely contractual basis. And whereas the contract which will be given to the First Party on the said Assignment which shall be a contractual engagement and shall continue for one year. And whereas the first party has read the terms and condition of this Agreement, and is willing to be engaged as an Insurance Medical Practitioner Doctor on the terms and conditions, and on the capitation remuneration, hereinafter appearing in this Agreement and which he/ she has signed in token of acceptance of terms and conditions and the remuneration mentioned therein. Now it is mutually agreed between the parties as under: 1. The engagement of First Party as Insurance Medical Practitioner Doctor will be purely contractual for a period of one year which can be extended as per extant rules of ESIC. 2. The contract period as mentioned in agreement will commence with effect from the date of signature by both parties and will be counted only from that date on which after the execution of this agreement by both parties, the First Party resumes duties in the forenoon of the day. 3. The First Party shall be entitled to receive from the Second Party capitation remuneration as decided by the ESIS/ ESIC as per rules and engagement during the period of twelve months from commencement of engagement under this contract or if this agreement terminated earlier by any party under the powers reserved herein then up to the period this agreement stands terminated. The first party shall get emoluments only for such of the above period when he/ she actually performed his/ her assigned work. No other amount shall be admissible to him/ her for the work actually rendered by him/ her. Income Tax as applicable shall be deducted at source. 4. The first party shall provide treatment to: (I) All insured persons(IP) of ESI Scheme and their dependent family members attached to him. (II) All persons whom he has accepted or agreed to accept for inclusion in his list and who have not yet been notified to him by the Director / REGIONAL DIRECTOR. (III) All persons who have been assigned to him and who have not yet been notified to him as having ceased to be on his list. (IV) Any insured person who needs treatment in case of an accident or any other emergency. (V) All persons for whom he may be required under the terms of the allocation scheme to provide treatment pending their acceptance or assignment to IMP. 5. The first party will be bound by the duties and functions and other aspects of engagement as detailed in the Manual for IMP provided to him. The salient features of his duties are as under: -

Page 20 of 22


Working hours:

Total no of working hours: Minimum 7 hrs a day. Working days 6 days a Week, excluding national holidays.

i. The clinic must be open for 3 hours in the morning, starting not earlier than 8.00 AM and not later than 9.00AM and 3 hours in the evening, starting not earlier than 5.00 PM and not later than 6.00PM.

ii. The clinic timings will be approved by Director, ESIS Medical Services/ Regional Director. The clinic hours and closed days must be displayed prominently in an appropriate place in the clinic.

iii. He is required to provide treatment to his patients as that generally given by a General Medical Practitioner. However he is required to treat his general patients and ESI beneficiaries on “first cum first serve” basis duly taking into account the need of the patient for urgent medical attention.

iv. He shall render whatever services possible in the beneficiary in the case of interest of emergency including difficult / complicated maternity cases.

v. He shall provide essential medicine in the clinic as per list of ESI Corporation. vi. In case the illness/condition of the patient is such that it requires treatment that is not within

his obligations/capacity, he may inform the patient and refer him to the nearest ESI/ ESI recognized / ESI Tie up / Govt. hospital. In case he makes arrangements for the patient’s transfer by ambulance or otherwise and any expense incurred by him on the transport shall be reimbursed to him by the Director, ESIS Medical Services / ESIC.

vii. He shall issue Medical Certificates, free of charge, as reasonably required for sickness, maternity, employment injury and death etc. as under regulations or as may be required from time to time by the Competent authority.

viii. He shall report death of an insured person or a family member and forward the Medical Record to the concerned Branch Manager, Branch Office of ESIC within 7 days. A copy of the same should be sent to the Director, ESIS Medical Services.

ix. x.

xi. He shall maintain ecords

as per requirement of State Govt. or ESIC. He shall maintain a record of each insured person on his list on the forms laid down by the Corporation in accordance with the instructions issued by the Corporation.

(XII

He shall

maintain registers that are required to be maintained and send monthly reports to the concerned Authorities as per formats provided to him.

(XIII

He shall furnish returns, such as statistics, drug requirement, Certificate Book etc. in such forms as prescribed by Corporation or the State Government or Director/AMO.

(XIV

He shall accept ESIC 86, TIC, ESIC-37, 105, 166, 48 etc. as prescribed by the Corporation, as prescribed entitlement for treatment.

(XV

He shall refer beneficiaries who require consultation with Medical Referee (MR).

(XVI

He shall afford the MR access at all reasonable times to his clinic where the records

Page 21 of 22


required by these terms of service are kept for the purpose of inspection of such records and to furnish to the MR such records or necessary information with regard to any entry therein, as he may request.

(XVII) He shall meet the MR at his request for the purpose of examining in consultation any

patient in respect of whom the IMP has sought the advice of the MR.

(XVIII) He shall answer in writing, if needed, within a reasonable period as specified by the MR, any query raised by the MR in regard to any prescription or certificate issued by the IMP or any statement made in any report furnished by him under these terms of service.

(XIX) He shall answer in writing, if needed, within a reasonable period as specified by the MR,

any query/clinical information regarding any IP to whom the IMP has declined a Medical Certificate.

6. The First Party will engage himself/ herself in the treatment of IPs and their families efficiently and diligently and to the best of his/ her ability. He/ she will devote his/ her whole time during the assigned clinic hours to his/ her work and duties and will not engage himself/ herself directly or indirectly in any trade, business or occupation on his/ her own account during that time. 7. That the contractual engagement which the First Party shall be required to do are understood by the parties signing this agreement. In witness whereof, the parties have signed the Agreement on the dates mentioned against their respective signature. SIGNATURE OF SECOND PARTY Place: Date:

SIGNATURE OF FIRST PARTY Place: Date

Witnesses 1.

Witnesses

1.

2. 2.

Page 22 of 22


Annexure-X

(Sign board should be 5ft long and 3ft wide) NOTICE BOARD

I.M.P. CLINIC FOR ESI BENEFICIARIES

Name of the IMP Dr.------------

TIMINGS: MORNING

Weekly Off:

EVENING

AVAILABILITY OF SERVICES

(I) (II)

Medical Attendance: All beneficiaries Investigations: Blood Sugar, Hb, Urine -alb/Sug as per requirement

(III) Distribution of Medicine: As per list of medicine available (IV) Medical leave certificate: As per requirement up to 7 days at a time. (V) Phone No. for Complaint: (VI) Complaint Register: Available with IMP

Note: Annexure-VI,VII & VIII as per Prints provided by the office as per standard format

1

Confidential ©UTIITSL Restricted Circulation

UTI Infrastructure Technology And Services Limited Insurance Division

Bill Processing Agency for Employee's State Insurance Corporation

Hospital Information System (HIS)

A. Hospital Name: ____________________________________________________________ B. Established in (Year): ___________ Regd No.: ________________________ C. Popular Name: _____________________________________________________________ D. ESIC Region under which user ID to be issued: __________________________________ E. Preferred User ID (Alphanumeric – Max 8 characters): ______________________________ F. Ownership:

□ Proprietorship □ Partnership □ Private Limited

□ Public Limited □ Charitable Trust G. PAN Number: ______________________________ H. Does Hospital has (NABH /NABL / CAP / JCI Accreditation) Please tick and enclose appropriate copy. I. Address: __________________________________________________________________ ___________________________________________________________________________ City __________________________ State ______________________ Pin Code ___________ Contact Number(s) _______________________________ Fax: _________________________ Mail ID ______________________________________________________________________ Website ______________________________________________________________________ J. Type of Emp Facility:

□ Dental □ Diagnostic □ Imagining Centre □ Hospital

Signature for MS/ CA

Page 1 of 5


http://www.esic.nic.in/index.php

2

K. Number of Beds:

□ More than 100 □ Between 51and 99 □ More than 30 □ More than 300

□ More than 500 □ Not Applicable L. Scope of Empanelment ( Clinical Services Provided by the Hospital )

Clinical Services NABH/NABL/ Super Speciality

Wef

Cardiology

Cardiothoracic Surgery Coronary Care Unit

Day Care Treatment Endoscopy (Diagnostic & Therapeutic)

Dentistry & Oral Surgery

Dermatology

Dialysis Emergency Medicine & Surgery

ENT Fertility Regulation

Gastroenterology

General Medicine General Surgery

Gynecology Obstetrics

Intensive Care Unit (Adult)

Intensive Care Unit (Pediatric)

Intensive Care Unit (Neonatal)

Others (Please Specify)

Clinical Services NABH/NABL/Super Speciality

Wef

Laser Treatment (Pl. Specify Procedure Done/Available

Nephrology Neurosurgery

Nuclear Medicine

Oncology Medical Oncology

Radiation Oncology

Surgical Oncology Ophthalmology

Orthopaedic Surgery Joint Replacement

Organ Transplant

Plastic & Cosmetic Surgery

Physiotherapy & Rehabilitation Medicine

Respiratory Medicine

Surgical ICU Plastic & Cosmetic


Signature for MS/ CA

3 Page 2 of 5

Confidential ©UTIITSL Restricted Circulation M. Scope of Empanelment (Diagnostic / Laboratory Services Provided by the Hospital / DC)

Diagnostic Services NABH/NABL/ Super Speciality

Wef

Diagnostic Imaging

CT Scanning

DSA Lab

Gamma Camera

MRI

PET

Ultrasound

X-Ray-Conventional

X-Ray-Digital


Laboratory Services

NABH/NABL/ Super Speciality

Wef

Clinical Bio-Chemistry

Clinical Microbiology

Clinical Immunology

Clinical Pathology

Blood Transfusion Services

Molecular Diagnostics

Others (Specify)

N. Statutory / Regulatory Requirements (Enclose Detailed Annexure) Furnish the list of applicable Statutory / Regulatory requirements the organization is Government by __________________________________________________________ O. Rate List for Procedures and Investigations of Empanelled Hospitals for ESIC beneficiaries

□ Hard Copy □ Soft Copy (CD) P. Bank Details Name of Bank : ____________________________________________________ Branch : _________________________________ City: ______________ A/C No. : ____________________________________________________ A/C Type : ____________________________________________________ IFSC Number : ____________________________ MICR No. : _____________ Name and Designation of Authorized Signatory: ____________________________________

Signature for MS / CA

4

Page 3 of 5


PS: Crossed Cancelled cheque need to be attached** Q. Contact Details I. CMD/MD/CMO Name : ___________________________________________________________ Designation : ___________________________________________________________ Mobile : _________________________Land Line: _________________________ Fax Number : _________________________Email: _____________________________ II. Coordinator for ESIC Name : ____________________________________________________________ Designation : ____________________________________________________________ Mobile : _________________________ Land Line: _________________________ Fax Number : __________________________Email: ____________________________ Alternate official : __________________________Email: ____________________________ Authorized Signatory for Hospital Name: Designation: Seal & Date: Signature for MS / CA ___________________________________________________________________________________ For UTI ITSL Office Use: Checked & verified all the documents. If found Satisfied Hospital Code No : ____________________________________ User ID : ____________________________________ Password : ____________________________________

Project Lead (IT) AVP (Insurance) Head Insurance

5 Page 4 of 5


Annexure: Self-Assessment Guide

Kindly provide the following mandatory annexures as applicable: I. Copy of MOA with ESIC with Anex-I (Scope of Empanelment) & Anex-II (Approved rate list with soft copy). II. Copy of PAN Card. III. Specimen copy of Cheque. IV. Income Tax Clearance - If eligible. V. Sales Tax Clearance - If eligible. VI. NABL/NABH Certificates with Anex (Scope of Accreditation). VII. Letter for super speciality status (if any).

Page 5 of 5

Documents

Page 1 of 2 - Employees' State Insurance · and the application fee of Rs. 300/- (non-refundable) be submitted with duly filled in Expression of Interest (E.O.I) form by way of Demand