Central Government Health Scheme

(CGHS)

Application form (CGHS-02)

for Empanelment of Eye Care Centres

National Accreditation Board for Hospitals & Healthcare Providers (NABH)

Quality Council of India
5th Floor, ITPI Building, 4 A, Ring Road, IP Estate
New Delhi - 110 002
Ph.: 011-42600600
E-mail: [email protected] Website: www.nabh.co
 SECTION: 1

GENERAL INSTRUCTIONS AND ELIGIBILITY CRITERIA

1. Categories of Cities. CGHS for purpose of empanelment has categorized the cities as:

Metro cities
Non-metro cities

2. Categories of Health Care Facilities: CGHS would consider the following categories of health
care facilities for empanelment :-

(a) Hospitals 1) General purpose hospitals// Multispeciality hospitals

2) Super specialty hospitals

(b) Diagnostic Centers

(e) Eye Clinics

(f) Dental Clinics.

3. Fire safety measures in the centres/clinics should be in place.

4. Compliance to bio-medical rules to be ensured

5. Submission of Application Forms:

a) The applications must be submitted along with relevant application form, application fee and
relevant annexure to NABH Office, New Delhi.

b) The applicable fee is as follows:

S. Type of facility Bed Strength Inspection Fee (Rs)

No.
(1) Hospitals More than 100 beds 35,000/-
Less than 100 beds 30,000/-

(2) Diagnostic, Eye & Dental Not applicable 25,000/-

Centres

Note: GST @ 18% will be charged on the above fees.

c) The fee has to be submitted either online or through a demand draft in favour of Quality
Council of India payable at New Delhi

d) Application forms should be submitted in one sealed envelope superscribed as ‘Application

for CGHS empanelment of hospital’.

e) Only typed application forms shall be accepted.

f) All the pages of Application and Annexures shall be serially numbered. Every page of
application form and Annexures need to be signed by the competent person.

g) The applicant shall nominate a nodal person for coordinating all activities related to
empanelment purposes.
 SECTION II

APPLICATION FORMAT FOR EYE CLINICS

PART 1

(Technical and Infrastructure Specifications of the Eye Clinic

1. Name of the Eye Clinic:

___________________________________________________________________

2. Contact Details of the Eye Clinic:

Name of the Contact Person

Street Address

City/Town____________________________________________________________

Locality/Village/Tehsil__________________________________________________

District______________________________________________________________

State

Telephone_______________________________ Mobile______________________

Email__________________________________________________________

Website____________________________________________________________________

SIGNATURE OF THE HEAD OR AUTHORIZED NOMINEE

 3. Location of Eye Clinic: Urban □ Rural □

Does the Eye Clinic have split location(s): Yes □ No □

If yes, address of the other location(s) and distance from main location
____________________________________________________________________
____________________________________________________________________

4. Ownership:

□Private – Corporate □Armed Forces

□PSU □Trust
□Government □Charitable
□Others (Specifiy.........................................................................................)
5. Year and month in which registered and under which authority (as per state
and central requirements)

____________________________________________________________________

6. Year and month in which clinical functions started:

____________________________________________________________________
 Remarks of QCI (NABH)

SIGNATURE OF THE HEAD OR AUTHORIZED NOMINEE

PART II: EYE CLINIC INFORMATIONS

Ser Subject Information given Remarks of

No by Eye Clinic QCI (NABH)
1. Building
Total Area (Sq.mt)

Built up Area (Sq.mt)

(Constructed areas of all floors)

Reception and waiting for Relatives (Specify

approx area)

PART III: STATUORY COMPLIANCE INFORMATION

(as per tender document requirement)

S Subject Information given by Eye Clinic Remarks of

No QCI (NABH)
STATUTORY Licence Valid Valid Status
COMPLIANCES /Certificate from to (Valid/Expired
(Mention “NA”
whichever is not
No. (if expired
applicable) details of
renewal
application
1. Fire NOC
2. AERB
Licenses/approvals/
registrations for
Radiology
Equipments (as per
the scope)

3. PNDT

4. Blood Bank license

5. MTP

6. Pollution Control
Licenses (Air,
Water and Bio-
Medical Waste)

7. Narcotic Drugs and

Psychotropic
Substances
(NDPS) license

8. Organ Transplant
(specify separately
type of organ
transplant
permitted)

9. Explosives license
for O2 tank etc

(Note: Attach relevant documents/certificates for all the above)

 SIGNATURE OF THE HEAD OR AUTHORIZED NOMINEE

Remarks by
QCI (NABH)

PART IV: FACILITIES APPLIED FOR

1. Applied for Empanelment as (Specify)

(a) Cataract/Glaucoma Remarks by

QCI (NABH)
(b) Retinal – Medical Retina/Surgical Retina

(c) Cornea

(d) Occuloplasty & Adnexa & other specialized treatment

(e) Strabismus

2. FOR IOL IMPLANT:-

Qualified ophthalmic surgeon with experience in Intra-ocular Lens implantation

Surgery + training proof of PHACOEMULSIFICATION surgery

Yes No
Name and Qualification

(i) Phacoemulsifier Unit IIIrd or IVth generation)

- minimum 2 with extra hand pieces

(ii) Flash/rapid sterilizer – one per OT

(iii) YAG laser for capsulotomy

(iv) Digital anterior segment camera

 (v) Ultrasound A Scan for IOL Power Measurement

(vi) Keratometer

- All Specialist employed on regular and visiting basis must possess M.C.I
recognized qualification
Yes No

- Catract Surgery by Phaco Emulsification

Yes No

- Backup facilities of Vitro-retinal surgeon deal with Phaco/IOL related

Complications. Yes No

Whether beds available

(General, Semi Private or Deluxe Room Yes No
(If yes, specify the number)

Gl. Ward Semi-Pvt Ward Pvt Ward

SIGNATURE OF THE HEAD OR AUTHORIZED NOMINEE

3. RETINA – MEDICAL RETINA /SURGICAL RETINA

- Availability of Equipments

a. Angiography of Retina – Retinal Fundus Camera/ Digital FA System Yes No

b. Vitrectomy Machine Posterior Segment Yes No

Remarks by
i. Endolaser and LIO QCI (NABH)
ii. Facilities for High Speed Cutting

iii Inbuilt Endoilluminator

iii. Inbuilt Air Fluid Exchange

iv. Inbuilt Phaco Fragmentation Facility

c. Retinal Laser – Cryomachine, Argon/Diode, Double Frequency, YAG with Multiple

Activator Mode, Laser Indirect Opthalmoscope for Retina Lab as well as OT

d. PDT Facility, OCT

- Indoor Facilities for admission with resident doctor/nurse/specialist

4. CORNEA
- Availability of Trained Surgeon in Corneal Surgery Yes No
Remarks by
a. Trained Eye Bank Technician QCI (NABH)
b. Eye Bank Specular Microscope

c. Culture/Storage Media
 d. Grief Councellor

e. Computerised Record Keepint Facility

- Approval by Competent Authority under Human Transplant Organs Act 1995 Yes No

- Facilities for processing, evaluation, lab investigation Yes No

5. OCULOPLASTY & ADENEXA.

Remarks of
Specific for Oculoplasty & Adenxa : QCI NABH
Specialised Instruments and kits for :

(a) Dacryocystorhinostomy

(b) Eye lid Surgery .eg ptosis and Lid reconstruction Surgery

(c) Orbital surgery

(d) Socket reconstruction

(e) Enucleation/evisceration

SIGNATURE OF THE HEAD OR AUTHORIZED NOMINEE

(f) Availability of Trained proficient Oculoplasty surgeon

who is trained for Oculoplastic, Lacrimal and Orbital Surgery

6. NEURO OPTHALMOLOGY/PAEDIATRIC OPTHALMOLOGY

Remarks of
- Availability of Equipment for Nero Opthalmology investigation
QCI NABH
- Optometrist/Orthoptician – at least two trained orthopticians/
optometrists, with experience of refraction of children

- Strabismus Surgery; Functional OT with Instruments need

for Strabisums Surgery

- Low Vision Aid

-
- Availability of Anesthetist

7. (a) INVESTIGATIVE FACILITIES Remarks of

(i) Syringing, Dacryocystography QCI NABH

(ii) Exophthalmometry

(iii) Ultrasonography – A & B Scan

(iv) Imaging facilities – X-ray, CT Scan & MRI Scan

(v) Ocular pathology, Microbiology service

(vi) Blood bank services

(vii) Consultation facilities fom related Specialties

such as ENT, Neurosurgery, Haematology, Oncology
 (viii) Laboratory Facilities (Inhouse/Outsourced)
(MoU for outsourced facilities)

(b) OPERATIVE (O.T.) FACILITIES

Specialized instruments & Kits for the following surgeries should be available
.
(i) Dacryo cystorhinostomy Remarks of
QCI NABH
(ii) Lid surgery including eyelid reconstruction &
Ptosis correction

(iii) Orbital surgery

(iv) Socket reconstruction

(v) Enucleation & Evisceration

(vi) Orbital & Abnexal Trauma including Orbital fractures

SIGNATURE OF THE HEAD OR AUTHORIZED NOMINEE

(vii) Kits for:

a) Cornea/sclera tear kit Remarks of
b) Small incision cataract surgery kit QCI NABH
c) Phacoemulsification operation kit
d) Squint surgery kit
e) Foreign body removal kit
f) Retinal surgery kit
g) Intravitreal injection kit
h) Corneal transplantation kit

(c) PERSONNEL
(I) Resident Doctor Support Remarks
of QCI
(ii) Nursing care 24 hours (NABH)

(iii) Resuscitative facilities

(v) Optometrist

8. STRABISMUS SURGERY
Remarks
(a) Functional OT with Instruments needed for strabismus surgery of QCI
(NABH)
Yes No

(b) Availability of set up for Pediatric Strabismus – Orthoptic room

with distance fixation targets (preferably child friendly) may have TV/VCR,
Less/Hess Chart
Yes No
9. GLAUCOMA

(a) Specific : Facilities for Glaucoma investigation & management. Remarks

of QCI
(i) Applanation tonometery (NABH)
(ii) Stereo Fundus photography/OCT/Nerve fibre Analyser
(iii) YAG Laster for Iridectomy
(iv) Automated/Goldmann fields (Perimetry)
(v) Electrodiagnostic equipments (VER, ERG, EOG)
(vi) Colour Vision – Ishiahara Charts
(vii) Contrast sensitivity – Pelli Robson Charts
(viii) Pediatric Vision testing – HOTV cards

(ix) Autorefractometers

SIGNATURE OF THE HEAD OR AUTHORIZED NOMINEE

Remarks
(x) Synaptophone (basic type with antisuppresion) of QCI
(NABH)
(xi) Prism Bars

(xii) Stereo test (Randot/TNO)

(xiii) Red – Green Goggles

(xiv) Orthoptic room with distance fixation targets

(Preferably child friendly) may have TV/VCR)

(xv) Less/Hess chart

10. MEDICAL RECORD SYSTEM Yes No Remarks

of QCI
(NABH)

11. EMERGENCY

- Basic Support Services Yes No

Declaration: I hereby declare that the details furnished above are true and correct to the
best of my knowledge and belief and I undertake to inform you of any changes therein,
immediately

SIGNATURE OF THE HEAD OR AUTHORIZED NOMINEE

Name:
Date:

Annexure 1

The compliance of the following will be assessed through observations, interviews

and/or documentary evidences

S.No Particular To be filled Remarks of QCI/NABH

by HCO
a. Process of registration of patients YES/NO

b. Initial assessment patient being YES/NO

done as required
c. Display of signage YES/NO

d. Scope of services displayed YES/NO

e. Procedure for infection control YES/NO

practices exists
f. Display of patients’ charter YES/NO
(including rights & responsibilities)
g. Training of the staff for the job YES/NO
assigned
h. Medical records (manual/electronic) YES/NO

i. Records are being kept in safe YES/NO

environment and confidentiality
 is being maintained
j. Procedures for maintaining YES/NO
personal files of staff
(regular/contractual
k. Availability of hand hygiene/hand YES/NO
washing facilities
l. Tariff list available YES/NO
Remarks of QCI (NABH)

SIGNATURE OF THE HEAD OR AUTHORIZED NOMINEE

Declaration: I hereby agree that the observations made by the assessor are correct to the
best of my knowledge.

SIGNATURE OF THE HEAD OR AUTHORIZED NOMINEE

Name:
Date:

SIGNATURE OF THE ASSESSOR

 SECTION III

RECOMMENDATIONS OF QCI (NABH)

1…..…………………………………………………………………………………..(Name of Eye
Clinic) is recommended/not recommended for empanelment for Central Government Health
Scheme (CGHS) for the following services:.

(Note: Mention R for Recommended and NR for Not Recommended. Strike out specialities
not offered for empanelment with an X)

(a) General Services Remarks of

QCI (NABH)
(i) Ophthalmology

(b) Specialised Services

(i) Cataract/Glaucoma

(ii) Retinal –
Medical/Surgical

(iii) Cornea

(iv) Occuloplasty & Adneza

(v) Strabismus

Seal of NABH SIGNATURE OF THE AUTHORIZED OFFICER

OF NABH/QCI