MEMBERSHIP REGISTRATION FORM

Choose File

Name of Medical Director/Owner/Partner-

Name of the Pathology

Address of the Pathology-

PIN-

City-

State-

E-mail Id-

Contact Details-

Year of Establishment-

Number of Staff/Lab Technician working-

Whether The Pathology Has Been Registered And Have Obtain Requirements As Prescribed Under The Law-

1. Certification from National Accreditation Board for Testing and Calibration Laboratories (NABL)?

2. Certificate from Good Clinical Practices (GCP)?

3. Registration with Shops and Establishments Act?

4. Registration with the Clinical Establishment Act?

5. Registration with biomedical waste disposal body?

6. Approval for waste generation from state pollution board?

7. No Objection Certificate (NOC) from the fire department?

NOC from municipality?

Whether the Pathology has been registered as – Proprietorship/ LLP/ Partnership

Existing policy or membership with any insurance company (Yes/ No) If yes, name of Insurance

Name of Policy-

Sum insured-

Any claim experience-

Any pendency or litigation relating to medical or personal-

If yes, please share the brief description about the nature and stage of litigation (this detail is required if you wish to have our membership for non-medico legal cases as well)-

If you wish to take membership for any colleague doctor/ please share their name with educational qualification-

Any other information-

DATE

DRAWN ON

CHEQUE NO./DD/NO

AMOUNT

NOTES

As per Services of Medins Legal LLP I hereby voluntarily declare to be a member of Medins Legal LLP for which I deposit Rs. for year/s and I am quoting my details above.

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