Sr.No.

NAME OF THE HOSPITAL

DISTRICT

No. of mithras

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

Ashwini Hospital, Akluj Dhanraj Giriji Hospital ASHWINI RURARL CANCER RESEARCH AND RELIEF SOCIETY YASHODHARA SUPER SPECIALITY HOSPITAL PVT.LTD. DR KASLIWAL MEDICAL CARE AND RESEARCH FOUNDATION KASLIWAL HOSPITAL Geetai Shushrushalaya and laproscopic Center DR. RAGHOJI KIDNEY HOSPITAL AND RESEARCH CENTRE PVT.LTD Shri Markandeya Hospital Jagdale Mama Hospital,Barshi Sub District Hospital Pandharpur DR CHIDGUPKAR HOSPITAL PVT LTD Ch.Shivaji Maharaj Sarvopachar Rugnalaya Solapur Anand Hospital LOKMANGAL JEEVAK HOSPITAL AKLUJ CRITICAL CARE AND TRAUMA CENTER Sasoon -BJ Medical College Pune Government Medical College & Hospital Miraj Hiremath Co-Operative Hospital, Barshi

Solapur Solapur Solapur Solapur Solapur Solapur Solapur Solapur Solapur Solapur Solapur Solapur Solapur Solapur Solapur Solapur Solapur Solapur

4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4

Not Signed MOUs (No. of Pending)

Specialties Empanelled (Only Codes)

Empanelment online status

Separate OP for RGJAY (Yes/No)

MOU Signed MOU Signed MOU Signed MOU Signed MOU Signed MOU Signed MOU Signed MOU Signed MOU Signed MOU Signed MOU Signed MOU Signed MOU Signed MOU Signed MOU Signed MOU Signed MOU Signed MOU Signed

M1,M10,M11,M14,M15,M2,M3,M5,M7,M8, M9,S1,S10,S11,S14 M1,M11,M2,M3,M5,M7,M9,S1,S10,S11,S12,S 13,S14,S2,S4,S5,S8,S9

M1,M2,S11

EMPANELLED EMPANELLED EMPANELLED EMPANELLED EMPANELLED EMPANELLED EMPANELLED EMPANELLED EMPANELLED EMPANELLED EMPANELLED EMPANELLED EMPANELLED EMPANELLED EMPANELLED EMPANELLED EMPANELLED EMPANELLED

YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES

M1,M10,M11,M13,M14,M3,M5,M6,M7,M8, M9,S1,S10,S11,S12,S14,S4,S5,S6,S8,S9 M1,M11,M6,M8,M9 M3,M5,M6,M8,S1,S11,S12,S13,S14,S2,S4,S5,S 6,S8,S9 M11,M3,M5,M6,M8,S1,S12,S13,S14,S2,S3,S4, S5,S6,S8,S9 M1,M11,M14,M15,M2,M3,M5,M6,M7,M8,M 9,S1,S10,S11,S12,S13,S14,S2,S3,S4,S5,S7,S8,S 9 M3,M5,M6,M7,S1,S10,S12,S13,S14,S2,S3,S4,S 5,S7,S9 M3,M7,S1,S10,S12,S13,S2,S4,S5,S6,S7,S8,S9 S1,S11,S12,S14,S4,S5,S8,S9 M10,M11,M3,M5,M6,S1,S2,S3,S4,S5
M1,M10,M11,M12,M2,M4,M5,M7,M8,M9,S1,S1 0,S14,S15,S17,S3,S4,S5,S6,S8,S9.

M11,M3,M5,S1,S14,S2,S3,S4,S5,S8
M1,M10,M11,M12,M2,M4,M5,M7,M8,M9,S1,S1 0,S14,S15,S17,S3,S4,S5,S6,S8,S9.

M10,M11,M14,M15,M3,M5,M6,M7,M8,M9,S 1,S10,S12,S13,S14,S2,S3,S4,S5,S6,S7,S8,S9 M1,M11,M2,M3,M5,M6,S1,S11,S12,S2,S3,S4, S5,S8

M3,M5,M6,S1,S3,S4,S5

OP Regn form printed with Marathi Guidelines at backside (Yes/No)

Infrastructure Availability KIOSK Computer Scanner Printer Bar Code Camera to 2Mbps Reader Mithra Iinternet

YES YES NO YES YES YES YES YES YES YES YES YES YES YES YES YES YES NO

YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES

YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES

YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES

YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES

YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES

YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES

NO YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES

Availability Speakers Extra USB Mike Webcam RGJAY Banner (Yes/No)

Banners placed near KIOSK Displaying Service Board

YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES NO

NO Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

placed near KIOSK Displaying Consultants list & Available timing (Yes/No) Instructions to RGJAY patients (Yes/No) NAME

MCO DETAILS CUG/Contact no. E-Mail

NO YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES

NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO

Dr. Inamdar Dr. Kiran Patil Dr. Rahul Kulkarni Dr. Suresh Manure Dr. Kasliwal Dr. Mrunal Bakare Dr. Anil Kenjer Dr. Vinod G Janai Dr. Uddhav Borade Dr. P Gaikwad Dr. Sameena Shaikh Dr. Ghate Amar Shende Dr Kantilal Daga Dr. Manjarekar Dr. Amol Dalvi N/A Dr.Sangram Gaikwad

9822062857 8275088985

udaysnikam@gmail.co m

8275088987 oo.com 8275088988 8275088992 8275088994 8275089065 8275089126 8275089131 9850798568 8275089990 NOT RECEIVED 9766051020 NOT RECEIVED

rahul_kulkarni1975@yah

dr.pankajgaikwad@gm ail.com

dramarsgmail.comhen de@

7875449880 accatc12gmail.com NOT RECEIVED NOT RECEIVED 827509773

MCCO DETAILS NAME CUG/Contact no. E-Mail NAME

MD/ CEO DETAILS CUG/Contact no.

Dr. K. Mahurkar Mr. Sham Pawar Mr. Nandkumar Panase Mr.Sidhling Burkal Mr. Alpesh Joshi Mr. Vijay Shinde Mr. Prashant Patil Mr. Sandeep Kharat Dr. Mahesh Shelwane Dr. Gawali Mr. Frances Disouza Dr. Harlkar Balasaheb Jangale Mr Vasant Kampali Dr. Dilip Fade N/A Dr. A.B. Ingale Nagayanwar Chandeshekhar

9850756743 827508986

udaysnikam@gmail.c om

Dr. Inamdar

9822062857

8275089068 m 8275088989 8275089063 8275088995 8275089073 8275089127 8275089133 9665935566 8275089991 NOT RECEIVED 8275089762 NOT RECEIVED 7875449884 NOT RECEIVED NOT RECEIVED

nspanse@rediffmail.co

Dr Nane

2184222699

dr.pankajgaikwad@g Dr. P Gaikwad mail.com

9850798568

balasahebjangale@g Amar Shende mail.com

9766051020

crohan121@gmail.co Dr. Manjarekar 7875449880 m

D/ CEO DETAILS E-Mail

udaysnikam@gmail. com

ashwinisociety@gm ail.com

dr.pankajgaikwad@ gmail.com

dramarsgmail.comh ende@

accatc12gmail.com

Visit Details of Field Team (Cumulative) Sr.No.

1

Date
Nil

NAME OF THE EMPLOYEE

Nil

Designation
Nil

Visit Details of Field Team (Cumulative) NAME OF THE HOSPITAL

Nil

DISTRICT
Nil

IN TIME
Nil

OUT TIME
Nil

Remarks
Nil

Sr. No. 1

NWH District

Date 11/28/2012

Outpatients
Hospital name Jagdale Mama Hospital,Barshi

Outpatients list
Patient name Patient Disease / Complaint

t
Disease Catogiry ( Eligible under 972 procedureYES/NO ) OP/IP Converted online to OP (If OP) (Yes/No)

OP

NO

Remarks

Contact No.

NIL

N W H DAILY REPORT FROM RICH HOSPITAL Column1 NWH DISTRICT Solapur Solapur Solapur Solapur Solapur Solapur Solapur Solapur Solapur

Column2

Column3

Sno

NWH NAME

NWH ID

1 2 3 4 5 6 7 8 9

JAGDALE MAMA HOSPITAL,BARSHI JAGDALE MAMA HOSPITAL,BARSHI JAGDALE MAMA HOSPITAL,BARSHI JAGDALE MAMA HOSPITAL,BARSHI JAGDALE MAMA HOSPITAL,BARSHI JAGDALE MAMA HOSPITAL,BARSHI JAGDALE MAMA HOSPITAL,BARSHI JAGDALE MAMA HOSPITAL,BARSHI JAGDALE MAMA HOSPITAL,BARSHI

HSP1411468 HSP1411468 HSP1411468 HSP1411468 HSP1411468 HSP1411468 HSP1411468 HSP1411468 HSP1411468

Column4

Column5

Column6

Column7 Health card no./Ration Card No 3553510

621125 947041

Patient name

Pt.District

Age

BHAMABAI SAMBHAJI GADAVE NAVNATH SHRIRAM MORE ANIL BABAN KALE MUKTABAI SHINDE ABHIJEET CHAVAN SAMBHAJ NETAKE SHAHANUDAR MULAMI YOURAJ SANGULE BALIRAM RAUT

Solapur Solapur Solapur Solapur Solapur Solapur Solapur Solapur Solapur

72 69 26 65 17 17 42 25 35

3624810
3462732

3553801 742765 690301 218082

Column8

Column9

Column10

Column11

Column12 DOA Preauth Approval 12/7/2012 12/12/2012 12/10/2012 12/13/2012 12/15/2012 12/15/2012 12/14/2012 12/14/2012 12/15/2012

Claim no.

Case status

DOA

DO pre sent

SOL/2012/P1R0/30/02354
SOL/2012/P1R0/30/02422 SOL/2012/P1R0/30/02391 SOL/2012/P1R0/30/02421 2012/P1R0/30/02481 SOL/2012/P1R0/30/02480 SOL/2012/P1R0/30/02461

SOL/2012/P1R0/30/02471
SOL/2012/P1R0/30/02478

sent for preutharization Society Approved Society Approved Society Approved Society Approved Society Approved Society Approved Society Approved Society Approved

12/7/2012 12/12/2012 12/10/2012 12/12/2012 12/15/2012 12/15/2012 12/14/2012 12/14/2012 12/15/2012

12/7/2012 12/12/2012 12/10/2012 12/12/2012 12/15/2012 12/15/2012 12/14/2012 12/14/2012 12/15/2012

Column13

Column14

Column15 Onbed Status (Onbed/Dayc are) Onbed Status (Onbed/Dayc Onbed Status (Onbed/Dayc Onbed Status (Onbed/Dayc Onbed Status (Onbed/Dayc Onbed Status (Onbed/Dayc Onbed Status (Onbed/Dayc Onbed Status (Onbed/Dayc Onbed Status (Onbed/Dayc Onbed Status (Onbed/Dayc

Column16 Eligible for Follow-up (Yes/No)

Column17 Counselled (if patient eligible for follow-up) (Yes/No)

DOS

CATEGORY

genral surgery GENITOURINARY SYSTEM CRITICAL CARE CRITICAL CARE Poly Trauma CRITICAL CARE Poly Trauma Poly Trauma CRITICAL CARE

Telephonic Intimations
Sno Telephonic Id: Name of the Patient
1

HEALTH NO Date of Tel. Int. taken

Registered Date of Regn (Yes/No) (By Mithra)

Nill

Nill

Nill

Nill

Nill

Nill

honic Intimations
After how many hours Surgery done Pre-auth Sent surgery done after (Yes/No) (Yes/No) tel.int. taken) Date of pre-auth Remarks

Nill

Nill

Nill

Nill

Nill

Follow-up Availed p Sno NWHDistrict FTL Name NWH Name NWH CUG Patient name

Follow-up Availed patients list Patient Dist Health No Claim No Date of Discharge FMP given Date

FMP Cycle 1/2/3/4

Updated online (Yes/No)

Field Remarks

Grievance Details
Sno NWH District Hospital name Patient name WAP card no. IP/OP

Grievance Details
Grievance Type Grievance Discription Action by Mithra FTL/DH/AM Action Status(Resol ved/Not) Remarks