APPLICATION FORM FOR EMPANELMENT OF HOSPITALS AND SURGEONS FOR CONDUCTING COCHLEAR IMPLANT SURGERY UNDER REVISED ADIP SCHEME (2014-15)

DETAILS OF HOSPITAL
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DETAILS OF CI SURGEONS ATTACHED TO THE HOSPITAL
Surgeon 1

Surgeon 2

Surgeon 3

DETAILS OF AUDIOLOGISTS ATTACHED TO THE HOSPITAL
AUDIOLOGIST 1

AUDIOLOGIST 2

AUDIOLOGIST 3

DETAILS OF HABILITATION PROFESSIONALS/SPEECH-LANGUAGE PATHOLOGISTS (SLPs) /AUDITORY VERBAL THERAPISTS (AVTs) ATTACHED TO THE HOSPITAL
PROFESSIONAL 1

PROFESSIONAL 2

PROFESSIONAL 3

DETAILS OF OTHER REHABILITATION PROFESSIONALS ATTACHED TO THE HOSPITAL
PSYCHOLOGIST

MEDICAL SOCIAL WORKER

ANY OTHER

DETAILS OF OTHER MEDICAL PROFESSIONALS ATTACHED TO THE HOSPITAL
PEDIATRICIAN

NEUROLOGIST

RADIOLOGIST

OPERATION THEATRE DETAILS
PART A
Manufacturer

No. Of units

Since when

Last Serviced

PART B
Details

PART C
Staff Number available

MENTOR SURGEON DETAILS (IF ANY)
File Name Upload

PRE- AND POST- COCHLEAR IMPLANTATION SERVICES AT THE HOSPITAL (Mention the charges for each test/evaluation. Attach relevant lists when possible)
Diagnostic

Medical

Post-implant Rehabilitation

Any hospital providing false information shall be viewed seriously and can amount to cancellation of accreditation. Accreditation can also be cancelled on recommendations of expert advisory panel in case of audit failure.

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Registered for CI

CI Surgery done

Hospitals Empanelled

Audiologists Registered

Habilitationists Registered

Updated:

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