Health Referral Network Form

Name of individual provider / organization: *

Type of provider/facility (clinic, dialysis center, diagnostic service, rehab, etc.): *

Contact person and role: *

Phone Number

Your Email *

Address and geographic coverage: *

Licensure / Clinic accreditation details: *

Areas of specialization / services offered: *

Services relevant for screening-based referrals (please specify which services require or are suitable for patient screening): *

Years of experience (minimum of 5 years including atleast 1 year of independent practice after supervised training): *

Proof of Specialized Training or experience in clinical ethics, patient safety, or quality-of-care frameworks (mandatory to upload certificate of such training): *

Fee structure (fixed, tiered, sliding-scale, discounted rates): *

Typical wait times for service: *

Confidentiality / patient privacy measures: *

Complaints / feedback mechanisms: *

Any automation/ digitalization of clinic (choose all that apply)? *

Admin processes automated

Digitalized services

Data collection automated for research and audits

Service available through (choose all that apply) *

In-person clinic for local patients

Telemedicine consultation

In-person facilities for international clients also (medical tourism)

Any potential services for medical tourism?

Name, and contact of a professional reference in BMY Health who can vouch for your ethical and clinical practice (or experience working with BMY Health): *

Website or any online advertisement link with service details: *

Transparency standards: does your clinic website/ page or other adds provide details of fee, wait times, accreditation, patient privacy and safety standards, any disclaimers, and provides all this info before availing the service? *

Interested in building smart clinic?

Yes

Submit