Memorandum of Understanding s32

Memorandum of Understanding

This memorandum of understand is entered into on______at New Delhi between East West Assist Pvt. Ltd, a third party administrator having it’s office at 37 Prithviraj Road, New Delhi 110011, represented by it’s C.E.O/M.D/C.O.O/ DIRECTORS’

And M/s ______Hospital, having its office at ______Herein after referred to as the hospital/nursing home/clinic.

Whereas the above two parties have decided to enter into an agreement to provide medical services to the health insurance sector and other corporations whereas the parties have decided to set out in writing the terms and procedures based on which the agreement becomes operational for a validity of 3 years.

Now this memorandum of understanding shall witnessed as under Purpose

To enroll the hospital as a participating healthcare provider to the East West Assist (EWA) group of service provider.

I EWA will provide the following services by virtue of this agreement 1. To provide insurance companies and employees of corporations information and access to quality health care. 2. To base with health insurance sector. 3. To offer cashless services to clients through the provider network. 4. To provide a twenty four hour alarm center 5. Being listed as a preferred care provider on the list of EWA 6. EWA will settle all approved, reasonable bills within 30 days of receipt of bills and supporting documents as details in the attached annexure

II The hospital/nursing home/clinic shall provide The ______Hospital/nursing home/clinic by virtue of being a preferred provider for EWA clients, the Hospital will provide the following services. 1. All clients will be received and treated on a priority basis at all times. 2. Soon after admission or arrival of the patient and no later than 24 hours, the EWA alarm center will be notified of the patients admission so that authorization of services may be processed and communicated by EWA to the hospital at the earliest. 3. The hospital will provide cashless services to EWA clients on obtaining authorization 4. The procedure for obtaining authorization is set out on a separate document that is being provided with this Memorandum of understanding. 5. For payment after authorization by EWA; the hospital must supply all document as listed in Annexure B. 6. All bills must be submitted promptly by the hospital but no later than seven days of discharge of the patient for prompt reimbursement. 7. No liability whatsoever shall develop on EWA in the event that facts have been concealed form EWA regarding the nature of the patients past or present history or on account of late submission or compliance of instructions as laid out and hence rejected by the insurance company. 8. The hospital shall always inform EWA in writing whenever their tariff is revised, some new services added or services/ facilities curtailed. III 1. The role of EWA is to ensure that the best possible services to their clients at the most reasonable and competitive costs. 2. It is made explicitly clear that in so far that any services that maybe provided by networked hospital provider to it’s clients in so far as it leads to any negligence or deficiency in service on part of the hospital wherein the client or his or her family members has taken treatment, EWA shall not in any way be liable or responsible for any such negligence, deficiency or damages.

Laws and Jurisdiction For all disputes that may arise by the virtue of this agreement, the laws of India shall apply and the jurisdiction shall be the courts at New Delhi, India, V

Medication This agreement can be modified from time to time by mutual consent of both parties

Signed for EWA Signed for Hospital Signature Signature Name Name Title/Designation Title/Designation

Name of Hospital/Nursing home/ clinic Date Date Annexure A

The hospital must provide the following information for the purpose of efficient functioning of the relationship with EWA and rapid processing of the claim.

1. A recent brochure of the hospital with current tariff list of services and procedures that are carried out at the hospital/nursing home/clinic.

2. List of various specialties available in your hospital

3. Name and phone number of persons who may be contacted on an emergency basis on holidays and at night, the contact details of the physician in charge of the patient should be given.

4. Any suggestions you may have for smooth functioning of this relationship.

5. Phone number, mobile number, all contact details of the owner, medical director or person with authority in charge of handing insurance formalities at the hospital Email address to be included if present.

6. Bank details of the hospital to be provided for a rapid wire transfer for payment.

7. If there is any change in address, contact phone number, fax, email, address, of the hospital, personal email, accounts section or contact person of the hospital, it should be intimated in writing by fax, post or email to EWA at the earliest. Annexure B

When the hospital submits bills, kindly ensure that all the following documents are attached:

1. Hospital bill in original with bill breakups; to be signed by signed by the patient before discharge form the hospital whenever possible,

2. Original reports of all investigations such as, ECG, X-ray, Ultrasound, CT scan etc., even if the test has been repeated, all repeat reports to be attached , All the reports should be signed by the treating physician or the medical superintendent.

3. Photocopy of the insurance policy of patient and their identification card (both sides of the card).

4. In case investigations are done at a place other than the hospital/nursing home/clinic, kindly provides original bills along with the original reports

5. Discharge Summary in original.

6. Pharmacy bills and breakups of the bill.

7. Doctor prescriptions in original.

8. Operation theater & OT consumables breakups

9. Claim form with signatures of patient. This list may be modified from time to time for efficient processing of claims and shall be intimated to you in writing.

Annexure C

When requesting authorization from the alarm center of EWA, kindly provide the following Information by phone call which should be promptly followed by fax or email.

1. Full name of patient 2. Age 3. Sex 4. Residential address 5. Name of insurance company/ corporation 6. Policy number 7. Identification card number 8. Dates of validity from ______to ______9. Name of Hospital 10. Name of treating doctor 11. Contact phone numbers of treating physician/surgeon 12. Patients location in the hospital/ bed number/ room number 13. With extension number of bedside telephone 14. Date and time of admission 15. Working diagnosis 16. Medication given and investigations done at the time of informing EWA 17. Approximate daily cost 18. Likely number of days the patient may be hospitalized 19. If any family members or companion is with the patient.

EAST WEST GROUP East West Rescue, Indian Air Ambulance, East West Medical Center, East West Assist 38 GOLF Links, New Delhi 110003 Phone: 011- 24690429, 24623738 Fax: 24690428

DETAILS OF PRIVATE NURSING HOME / HOSPITAL

Name of hospital

Address

Phone numbers

Website Total number of beds

Double room (approx. charge)

Single room (approx. charge) Name of Medical Director

Contact number / Mobile : Name of medical superintendent Contact number / Mobile : In case of emergency / notification calls from our organization to your hospital, the

Person to contact : Name and contact number / Mobile : Name of Financial Officer / Accounts officer Contact number / Mobile : Hospital Services

Are the following available? YES NO Imaging X-ray Doppler Ultra sound CT scan MRI Barium studies

Laboratory Hematology Biochemistry Serology If in-house ABG (arterial blood gas examination) not available. Is it possible to send the sample elsewhere? Histopathology HIV 1 HIV 2 Cardiology Electrocardiograph Echo Defibrillator Cardiac monitor Pacing – Temporary --Permanent TMT Holter

Respiratory Spirometry Nebulizer Ventilator Oximetry BIPAP Pharmacy 24 hours and only for inpatients? Available to general public?

Blood bank – In house? In house – is blood checked for - HIV 1 HIV 2 Hepatitis B Hepatitis C If not in hospital, which blood bank’s is used Please provide name and phone number of the bank. Surgery Operation theater ( number minor/major) C arm available CTVS (cardio thoracic vascular surgery) Cardiac Bypass General surgery Neurosurgery Please add other if available

Emergency Ambulance- size and type of vehicle available

Emergency room 24 hour resident in the hospital Specialists on call

Or present 24 hour in the hospital

Nephrology Peritoneal Dialysis Hemodialysis Renal transplant Gastroenterology Endoscopy Colonoscopy ERCP

Neurology EEG (electro encephalogram) Sleep lab EMG / NCV (electro myelogram / nerve conduction studies)

Orthopedics Acute Trauma can be rapidly operated Joint replacement

Special care units Intensive care unit –ICU Intensive Coronary Care unit – ICCU Pediatric intensive care unit – PICU

Maternity / OBGYN Delivery / labor room Gyne operations (hysterectomy etc.)

Pediatrics Yes No Ventilator Nursery Incubator Neonatologist

Other departments Please add other specialties, services, facilities available in Your institution Dentistry Dietitian Dermatology Endocrinology Hematology Psychiatry Physiotherapy Oncology

Other information Food for patients available Private duty nurses available Oxygen

MOU signing date Validity till

Form filled by: Signature: Designation: Please attach hospital/nursing home/clinic brochure, charge schedules of laboratory, Investigation, Room charges etc. Please add additional sheets if required.

THANK YOU FOR TAKING THE TIME TO FILL THIS FORM No membership fee required