Welleazy | Add Service Provider

Type of Provider

Type of Provider *

Type of Partner Ship

Type of Specialty *

Type Of Ownership *

Corporate Group *

Provider Basic Information

Center Name *

Email Id *

Mobile Number *

Landline No

STD Code

Fax

Plot No

Address *

Note: Please don't use Special character(&#@*%)

Area/Town *

State *

City/District *

Pin Code *

Only 6 digit allowed

Service Pin Code *

Website

Visit Type *

Google Address

Short URL

Location Link

DC Unique Name

Vendor Registration Name

SPOC Person Details

Provider Recognition

Recognized By

Accreditation

Provider Manpower & Staffing

No. Of Doctors/Consultants (Full Time)

No. Of Doctors/Consultants (Visiting)

Department	Title	Email	Cell No.
Head of Insurance Desk	Select Any One Dr. Mr. Mrs. Ms.	Enter Valid Email	Enter Valid Mobile Number
Fund Transfer Detail to be updated to	Select Any One Dr. Mr. Mrs. Ms.	Enter Valid Email	Enter Valid Mobile Number
Cashless OPD Related Communication to be updated to	Select Any One Dr. Mr. Mrs. Ms.	Enter Valid Email	Enter Valid Mobile Number
Chairman/Manging Director/CEO/Unit Head of the organization	Select Any One Dr. Mr. Mrs. Ms.	Enter Valid Email	Enter Valid Mobile Number

Provider Services

Service Type

Ambulance

If Ambulance Yes

Health Check Up

No. Of BLS Ambulances

No. Of ACLS Ambulances

Specialties Available

Radiology

Status

Services

Discount

Price

Time Slot (From-To)

X-ray

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Digital X-ray

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Ultra Sound

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Color Doppler

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Mammogram

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CT Scan

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MRI

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PET Scan

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Nuclear Imaging

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ECG

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PFT

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TMT

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2D Echo

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Fluoroscopy

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Pathology

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Hospital Bank Details

Bank Account Number

Account Holder Name

Bank Name

Branch

IFSC Code

Preferred Payment Terms

Upload Cancelled Cheque

Discount Details

Add Discount

Voucher Details

Add Voucher

Other Details

MOU Signed Received

Yes

No

MOU Received Date

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Please Select Date

Client Company

Remarks

Document Upload

(Only .png |.jpg |.jpeg|.pdf files allowed with size below 1 MB)

Registration Certificate :

PAN Card :

GST certificate :

LOL Legal Document :

Agreement Legal Document :

Vendor Registration Form :

Any other Documents (Specify) :

MOU Signed Copy :

List of Provider Branch(s) :

Fire safety license :

Pre-Natal Diagnostic Techniques (PNDT) License :

Radiation Protection Certification :

No Objection from Pollution control :

BIO Medical Waste Management certificate/ Agreement :

Building permit :

NABH / NABL / ISO / JCI / Other :

Cancelled cheque / Bank Statement / Passbook :

NEFT Declaration form (RTGS/NEFT Payment Authorization Form) :

Hospital OPD Tariff :

List of TPA / Insurance company with which provider is registered :

List of Consultants :

OPD Schedule for Consultants :

	S	M	T	W	T	F	S
53	28	29	30	31	1	2	3
2	4	5	6	7	8	9	10
3	11	12	13	14	15	16	17
4	18	19	20	21	22	23	24
5	25	26	27	28	29	30	31
6	1	2	3	4	5	6	7

Time Picker
12:00 AM	1:00 AM	2:00 AM
3:00 AM	4:00 AM	5:00 AM
6:00 AM	7:00 AM	8:00 AM
9:00 AM	10:00 AM	11:00 AM
12:00 PM	1:00 PM	2:00 PM
3:00 PM	4:00 PM	5:00 PM
6:00 PM	7:00 PM	8:00 PM
9:00 PM	10:00 PM	11:00 PM

	S	M	T	W	T	F	S
53	28	29	30	31	1	2	3
2	4	5	6	7	8	9	10
3	11	12	13	14	15	16	17
4	18	19	20	21	22	23	24
5	25	26	27	28	29	30	31
6	1	2	3	4	5	6	7

	S	M	T	W	T	F	S
53	28	29	30	31	1	2	3
2	4	5	6	7	8	9	10
3	11	12	13	14	15	16	17
4	18	19	20	21	22	23	24
5	25	26	27	28	29	30	31
6	1	2	3	4	5	6	7

Add Serivce Provider Network Manager Contact Details

Type of Provider

Provider Basic Information

SPOC Person Details

Provider Recognition

Provider Manpower & Staffing

Provider Services

Hospital Bank Details

Discount Details

Voucher Details

Other Details

Document Upload

	S	M	T	W	T	F	S
53	28	29	30	31	1	2	3
2	4	5	6	7	8	9	10
3	11	12	13	14	15	16	17
4	18	19	20	21	22	23	24
5	25	26	27	28	29	30	31
6	1	2	3	4	5	6	7