Document text
eC Agreement (26.11.19)
(TO BE EXECUTED BY THE SUCCESSFUL PARTICIPANT AT TIME OF AWARD OF CONTRACT)
AGREEMENT BETWEEN ESIC AND CHEMIST
[UNDER MODIFIED INSURANCE MEDICAL PRACTITIONER (mIMP) SCHEME] (To
be executed in Rs 100 Non-Judicial Stamp paper)
THIS AGREEMENT (the “Agreement”) is made and entered on the __________ day of
____________ in the year two thousand and ___________, on the terms and conditions herein
contained:
BY AND BETWEEN
Employees’ State Insurance Corporation (ESIC), represented by Dr. / Mr. / Mrs.
________________________, Age ____, Gender _____, S/O,D/O,W/O_________________,
working as Regional Director/ SRO In-charge, at Employees’ State Insurance Corporation (ESIC)
___________________(place of office with full address), (hereinafter referred to as ‘ESIC’) which
expression shall, unless it be repugnant to the context or meaning thereof, be deemed to mean
and include its successors and assigns) of the ONE PART (FIRST PARTY).
And
Dr. / Mr. / Mrs._____________________, Age ________, Gender & address _________
S/O,D/O,W/O_________________________
Resident
of
_________________________,
representing __________________________ (Name of Chemist / Pharmacy & address),
designation / in the capacity of __________________________ [hereinafter referred to as the
‘empanelled Chemist (eC) under mIMP Scheme] which expression shall, unless it be repugnant
to the context or meaning thereof, be deemed to mean and include its successors and assigns)
of the OTHER PART (SECOND PARTY).
WHEREAS, the Second Party (eC) has read the terms and condition of this Agreement,
and is willing to be engaged as an empaneled Chemist on the terms and conditions, hereinafter
appearing in this agreement and which he/she has signed in token of acceptance of terms and
conditions mentioned therein.
WHEREAS, the empaneled Chemist has agreed to provide Medical services to bonafide
ESIC Beneficiaries as per stipulated terms and conditions for upto a period of _________.
WHEREAS, each Party is duly authorized and capable of entering into this Agreement.
NOW, THEREFORE, in consideration of the above recitals, the Parties hereby agree as follows:
a. TERMS / DURATION /TERMINATION:
i.
The engagement of Second Party as empaneled Chemist will be purely contractual
during the period of this contract and shall be valid for initial period of one year,
renewable every year on satisfactory performance services, and extendable for
maximum period of 3 years under same terms and conditions . If either party seeks
to terminate this Agreement, the terminating party must provide 30 days’ notice
to the other party or payment @ Rs. 10,000 (Rupees Ten Thousand only) in lieu of the
notice period.
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eC Agreement (26.11.19)
ii.
However, the FIRST PARTY reserves the right to terminate the Contract by giving
notice of Seven days, if the SECOND PARTY is in breach of contract. Also, the FIRST
PARTY is entitled to rescind the contract by reason of SECOND PARTY’s
misrepresentation, undue influence or duress or where some unforeseen event that
may prevent the parties to perform the contract.
iii.
The contract period as mentioned in agreement will commence with effect from the
date of signature by both parties and will be counted only from that date on which
after the execution of this agreement by both parties.
iv.
The Regional Office/DCBO, at the time of empanelment of an eC shall be tagging an
IMP Clinic so as to help beneficiaries avail services from these eC. More than one eC
can be attached to an IMP Clinic or vice versa to bring in ease of service delivery and
competition. There shall be no capping on number of IP-Family units that can be
tagged to any eC.
b. THE SCOPE OF SERVICES:
The eC shall provide services to the Beneficiaries and abide by instructions as
specified in “Annexure D” (the “Services”). However, the instructions are liable for
modifications without prior notice.
c. LISTED MEDICINES:
The SECOND PARTY (eC) shall supply ‘Listed Drugs’ as per “Annexure B” to the ESI
beneficiaries free of cost and charge ESIC at flat _________ ( in words ) % discount
on the MRP printed on the Drug/medicine package. Prescribed Drugs and Dressings
issued to the beneficiaries outside the Specified List (‘Unlisted Drugs’) shall be
charged from the beneficiaries at flat ____ ( in words ) % discount on the MRP
printed on the Drug/medicine package, as agreed upon by him and on the basis of
quote approved by ESIC.
d. OTHER TERMS & CONDITIONS
1. The SECOND PARTY (eC) agrees to supply Allopathic Drugs, Dressings and
Consumables to the ESI beneficiaries against the prescription of Insurance Medical
Practitioner (IMP) registered under the mIMP Scheme.
2. The eC understands that the MRP of items/drugs on which the rebate offered in
percentage is inclusive of all taxes and duties payable during the contract period.
3. The eC should be complying with the statutory rules, regulations and licenses
pertaining to trade, including that of the Drugs and Cosmetics Act, 1940 and
amendments made thereafter, and submit copies of relevant document to ESIC.
4. The eC shall provide cashless services to the ESI Beneficiaries only when the Drugs
issued from the ESIC defined ‘Listed’ items (“Annexure B”) prescribed by the
registered IMP Clinic. This amount shall be claimed at the end of the month from
ESIC, for reimbursement.
5. If ‘Unlisted drugs’ (Drugs outside the items Listed/published by ESIC) is prescribed,
the beneficiary shall have either of the two options: One: To pay from pocket at the
agreed discounted price to avail the drugs from the eC and later claim reimbursement
from ESIC/DCBO producing copies of bills, proof of receipt and prescription written
on the Health Passbook by the registered doctor; OR, Two: avail these from DCBO,
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eC Agreement (26.11.19)
free of cost. This implies that for unlisted drugs, the eC shall charge the cost from the
patient as per the agreed upon rate (Discounted on MRP) upfront when purchased
by the beneficiary and issue the Bill and capture information in the relevant fields of
Mobile App.
6. The eC shall submit claims to ESIC (DCBO/BO) for the cashless services provided to
the ESI Beneficiaries. Branch Office/DCBO/Regional Office shall reimburse claims
through online method(s), deducting any statutory requirements/taxes, as deemed
fit.
7. Non-eligible IP or his family member may be treated as a private patient.
8. The eC will maintain sufficient stock of the Medicines at all times during the contract
period for uninterrupted supply to user and shall arrange supplies in accordance with
the nomenclature, specifications.
9. The eC shall ensure that supplies of Medicines as and when required, to be made in
original packing of manufacturer. The eC acknowledges that tampering on the
packaging details or alteration in the batch number, expiry date or MRP or any such
information is a criminal offence, and eC shall be held responsible and accountable
for any or all legal consequences.
10. The second party agrees that, in case of failure or refusal by second party to supply
the Medicines to the Beneficiaries during the contract period, the contract is liable to
be cancelled at his risk and cost and any extra cost involved in arranging supplies from
alternative source will be recovered from his subsequent/pending bills. Irregular
supplies/ failure to fulfill the terms of contract may entail for closure of contract.
11. The eC acknowledges that supply, storage and distribution of spurious or
substandard drugs is a criminal offence and agrees not to indulge in any such criminal
activities, for which he shall be liable for prosecution by Law.
12. The eC undertakes that under any circumstances if his/her license for executing
business is cancelled/ suspended by any authority / Govt., this contract shall be
terminated automatically.
13. The eC understands that the it shall be liable for administrative action in the event of
lapse on his/her part to comply with the terms and conditions and on the
supplying/items of sub-standard quality or if proven to have followed unscrupulous
practices apart from the liability of penal action for violating the law of the land.
14. The eC undertakes that his/her firm is not blacklisted /deregistered currently and has
not been Blacklisted /deregistered by any other Govt. institution/ Organization
during the last three years for any reason including supplying sub- standard
medicines.
15. The eC undertakes that he/she has not been convicted by any court of law in any
matter related to supplying sub- standard Medicines/Other items or on any other
grounds.
16. The eC undertakes that his/her firm is not convicted in an offence under the
prevention of Corruption Act, 1988, or under the Indian Penal Code or any other law
for the time being in force, for any cause of life or property or causing a threat to
public health as part of execution of a public procurement contract.
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eC Agreement (26.11.19)
e. RESPONSIBILITY OF THE SECOND PARTY:
The First Party (ESIC), in all good faith shall pay remuneration, as defined and as agreed,
to the Second Party, within 15 days of receipt of complete and correct reimbursement
Claim from the Second Party.
f. INDEPENDENT CONTRACTOR STATUS
The Second Party shall be serving as an independent contractor in providing the Services.
Under this Agreement, the Second Party is neither an employee nor a partner of ESIC.
g. GOVERNING LAW.
The laws of the State of India govern all matters arising out of or relating to this
Agreement and the transactions it contemplates, including, without limitation, its
interpretation, construction, validity, performance, and enforcement.
SIGNATURE OF FIRST PARTY
SIGNATURE OF SECOND PARTY
DATE:
DATE:
PLACE:
PLACE:
WITNESS 1:
WITNESS 2:
NAME:
NAME:
DATE:
DATE:
PLACE:
PLACE:
WITNESS 3:
WITNESS 4:
NAME:
NAME:
DATE:
DATE:
PLACE:
PLACE:
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eC Agreement (26.11.19)
“ANNEXURE D”
THE SCOPE OF SERVICES FOR EMPANELLED CHEMIST (eC)
A. SCOPE OF SERVICES:
1. eChemist will download the ESIC “Dhanwantri” mobile app from Google Playstore into
his Android device to log-in with the ESIC issued user credentials (User ID & Password).
The SIM Card of the mobile number registered with ESIC must be in the same smartphone
device where the Mobile App has been downloaded to authenticate user through OTP.
2. The eC shall ascertain that the Health Passbook (a small booklet containing about
100 pages with system generated beneficiary credentials affixed on it) and the ePehchan
card is carried by the ESI Beneficiary every time he visits the eChemist for availing
medicine/services.
3. At the time of visit by patient (ESI Beneficiary), eChemist will check ‘health passbook’
where the drugs are prescribed/written by hand by the empaneled IMP and shall
ascertain bonafide status of the ESIC beneficiary. The authenticated Health Passbook
booklet serves as a tool for identifying the credentials of the ESI beneficiary and meant
for viewing consultation/drug advice prescribed by the doctor. The credentials generated
from the system contain the demographic details of a member of the IP-family and
Unique Health Identification (UHID) Number. In addition, it contains mobile no., passport
size colored photograph and QR Code. Each IP-Family unit shall have one common e-
Pehchaan card but each member of the family including IP shall have separate Health
Passbook containing Unique Health Id.
Normally, the validity of the Health Passbook is till the last day of the current eligible
Benefit Period corresponding to the previous Contribution Period and is recorded on the
Health Passbook. In case of doubt, additional government issued photo-identity proof
may be sought to verify identity and prevent unethical practices or impersonation.
4. Empaneled Chemist will log-in to ESIC Dhanwantri App, feed-in the beneficiary’s
credential to ascertain the Check-in number (OPD Number) generated by the IMP Clinic
as also mentioned on the prescription page of the Health Passbook, against which
services are to be rendered.
5. Once the genuineness of ESIC Beneficiary has been ascertained, he shall dispense only
the prescribed drugs on the Health Passbook. He shall prepare bill/invoice through his
own system and obtain beneficiary’s signature on the cash memo as proof of delivery
while handing over the medicines.
6. Against the Check-in number of a patient in the ‘Dhanwantri Mobile App”, the eC shall
enter the cash memo (bill) number and date, amount/cost of the dispensed drugs taking
account of the rebate/discount on MRP as agreed upon. Thereafter, using mobile camera
in the Dhanwantri App eC shall take and upload clear and visible photograph(s) (scan and
upload function) of:
a. cash memo of listed drugs
b. cash memo of unlisted drugs, if any, and
c. IP/family member holding prescription page of Health Pass book and aforesaid cash
memo(s) in hand.
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eC Agreement (26.11.19)
7. This process shall be irrespective of whether eChemist has issued “Listed” or unlisted
drugs. However, the “Listed” drugs are to be issued cashless without charging anything
to the beneficiary and original Bill / Cash memo needs to be retained by the eC for
submission to ESIC later to claim reimbursement.
8. Original Bill / Cash-memo shall be required to be handed over to the Beneficiary when
unlisted prescribed drugs are purchased by the Beneficiary with the agreed upon
discounted rate on MRP, paying from his pocket.
9. Irrespective of whether purchased by the beneficiary or availed cashless, the original Bill
/ Cash-memo must contain beneficiaries’ signature certifying receipt and uploaded these
signed bill in the mobile app through scan function.
10. eC will also keep the photo/ scanned copy of prescription page(s) of the booklet and Bill
and get it signed by patient/ attendant for future claim for reimbursement in case of
cashless services.
11. At the end of the calendar month in which services rendered, and within 7 days of the
next calendar month the eC shall submit claim in the prescribed format to Branch office/
DCBO/Regional Office for processing of payment.
12. The eC shall submit a claim in Hard copy to ESIC (DCBO/BO) for the cashless services
provided to the ESI Beneficiaries during previous month. It is required to be submitted in
prescribed proforma in the 1st week of every subsequent month. The claim should be
supported with summary statement (may also be generated through mobile app),
medicines bill(s) and the proof of receipt of medicines by the patient, on a monthly basis.
Branch/DCBO of ESIC will verify claim bills and submit to RO for cashless online payment
or through ECS, deducting any statutory requirements/taxes, as deemed fit.
13. Upon submission of monthly or quarterly or annual claims, payment of eligible amount
will be made on-line through ECS by Dispensary cum Branch Office (DCBO) in the district/
nearest Branch office/ESIC Office. Hence Bank account and PAN details of eC are required
to be submitted mandatorily.
SIGNATURE OF FIRST PARTY
SIGNATURE OF SECOND PARTY
DATE:
DATE:
PLACE:
PLACE:
WITNESS 1:
WITNESS 2:
NAME:
NAME:
DATE:
DATE:
PLACE:
PLACE:
WITNESS 3:
WITNESS 4:
NAME:
NAME:
DATE:
DATE:
PLACE:
PLACE:
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eC Agreement (26.11.19)
Annexure “2”
ECS Mandate form
Second Party Details to receive payment through e-payment
1.
Name of the IMP/Chemist/Diagnostic Centre:
2.
Address of the IMP/Chemist/Diagnostic Centre:
3.
Telephone no. of the IMP/Chemist/Diagnostic Centre:
4.
Name of the Account Holder:
5.
Bank Account No. :
6.
Type of the account (S.B., Current or Cash Credit):
7.
Name of the Bank :
8.
Name of the branch :
9.
Bank Address :
10.
Bank Telephone No. :
11.
MICR code number of the bank and branch:
12.
IFSC code number of the Bank & branch
N. B. Please attach a blank cancelled cheque or photocopy of a cheque or front page of your bank
passbook issued by your bank
I, hereby, declare that the particulars given above are correct and complete. If the transaction is
delayed or not effected for reason of incomplete or incorrect information given by me as above,
I would not hold the ESIC responsible.
Dated ___________
(___________________________)
Signature of the Second Party
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eC Agreement (26.11.19)
Reimbursement Claim Form for empanelled Chemist (mIMP Scheme)
To,
The In charge,
BO/DCBO, ___________________________________,
Employees’ State Insurance Corporation,
_____________________________________________
_____________________________________________
PIN ________________
Sub: Reimbursement of claim for providing Medicines for the Month & Year of
______________.
Ref:- Name of Chemist / Centre: _____________________________ e-Chemist
User ID / Reference No: ______________________
Sir/Madam,
I am submitting the claims in prescribed Proforma for providing cashless services [supplying
Medicine(s)] to the eligible ESI beneficiaries under mIMP Scheme for the month & year
___________. The duly receipted original bill(s)s/Cash memo(s) and photocopy of relevant
prescription page(s) of the Health Passbook have been appended for perusal.
Thanking you.
Enclosures:
1. Claim details (as per Prescribed Proforma – Y)
2. Mandate Form (as per Annexure 2)
3. Original Bills / Cash memo of all claims
4. Photocopies of Prescriptions
5. ______________________________
Yours Sincerely,
Date:
Place:
Signature:
Name: __________________________
Mobile No.: ______________________
Email ID: ________________________
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eC Agreement (26.11.19)
Proforma –Y
Claim Submission Form (for empaneled Chemist)
for the Month & Year of _________
Name of
Beneficiary,
Age, Gender
Insurance No.
UHID No.
Sl.
No
OPD Check-in
No.
Check-in
Date
Bill
No.
Bill Date
Billed Value
(MRP)
Rebate
(if any)
Claimed
value (Rs)
Remarks
(if any)
Name of
Beneficiary,
Age, Gender
Insurance No.
UHID No.
Sl.
No
OPD Check-in
No.
Check-in
Date
Bill
No.
Bill Date
Billed Value
(MRP)
Rebate
(if any)
Claimed
value (Rs)
Remarks
(if any)
Date ___________________
Signature _______________
S T A M P
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eC Agreement (26.11.19)
“Annexure B”
ESIC Essential drug List (Detailed) (Subject to modification from time to time)
Sl.
No.
Sub Category Name
Generic Name
Indicative Brand Names
1
CAPS/TAB - ANTI
COAGULANTS/ANTI-
THROMBOTICS
Acetyl Salicylic Acid (Aspirin) Caps/Tab. 75mg.
Such As: ASA 75mg, Aspirin 75mg, Eprin 75mg, Sprin
75mg, etc.
2
CAPS/TAB - ANTI
COAGULANTS/ANTI-
THROMBOTICS
Acetyl Salicylic Acid (Aspirin) Caps/Tab. 100mg.
Such As: Aspin Tab. 100mg, Manospirin Tab., Colsprin
Tab., Alpyrin Tab., etc.
3
CAPS/TAB - ANTI
COAGULANTS/ANTI-
THROMBOTICS
Acetyl Salicylic Acid (Aspirin) Caps/Tab. 150mg.
Such As: Ecosprin 150 Tab., Vasoprin Tab., Manosprin ER
Tab., Nusprin Tab., etc.
4
CAPS/TAB - NON-OPOID ANALGESIC
Acetyl Salicylic Acid (Aspirin) Caps/Tab. 300mg.
Such As: Aspirin 300mg., etc.
5
CAPS/TAB - NON-OPOID ANALGESIC
Acetyl Salicylic Acid (Aspirin) Caps/Tab. 325mg.
Such As: Ecosprin 325 Tab., Cotasprin Tab., etc.
6
CAPS/TAB - NON-OPOID ANALGESIC
Acetyl Salicylic Acid (Aspirin) Caps/Tab. 500mg.
Such As: Aspirin 500mg, Otaspirin, etc.
7
CAPS/TAB - DRUGS ACTING ON JOINTS
Allopurinol Caps/Tab. 100mg.
Such As: Galoric Tab., Zyloric 100 Tab., Purinol Tab.,
Ranloric Tab., etc.
8
CAPS/TAB - DRUGS ACTING ON JOINTS
Allopurinol Caps/Tab. 300mg.
Such As: Zyloric 300 Tab., Aloric 300 Tab., Purinol Tab.,
Alloric Tab., etc.
9
CAPS/TAB - ANTI DEPRESSANTS
Amitriptyline Caps/Tab. 10mg.
Such As: Valine 10 Tab., Amitor 10 Tab., Raitrip 10mg.,
Amiline Tab., etc.
10
CAPS/TAB - ANTI DEPRESSANTS
Amitriptyline Caps/Tab. 25mg.
Such As: Amitryp 25 Tab., Amoten 25 Tab., Tryptomer
25mg. Tab., etc.
11
CAPS/TAB - ANTI DEPRESSANTS
Amitriptyline Caps/Tab. 50mg.
Such As: Tryp 50mg. Tab., Amypres 50mg. Tab., Tridep
Tab., Amitor Tab., etc.
12
CAPS/TAB - ANTI DEPRESSANTS
Amitriptyline Caps/Tab. 75mg.
Such As: Tridep 75mg, Tryp 75mg, Amypres 75mg. Tab.,
Amitor 75 Tab., etc.
13
CAPS/TAB - ANTIHYPERTENSIVES
Amlodipine Caps/Tab. 2.5mg.
Such As: Amlokind 2.5mg, Numlo 2.5mg, Ampine Tab.,
Myodipine Tab., etc.
14
CAPS/TAB - ANTIHYPERTENSIVES
Amlodipine Caps/Tab. 5mg.
Such As: Amlomay Tab., LAMA 5 Tab., Stamlo 5mg. Tab.,
Amdep 5 Tab., etc.
15
CAPS/TAB - ANTIHYPERTENSIVES
Amlodipine Caps/Tab. 10mg.
Such As: Amodep 10mg, Amlokind 10mg, Neocard 10
Tab., Amlokos 10 Tab., etc.
16
CAPS/TAB – ANTIBIOTICS
Amoxycillin Caps/Tab. 250mg.
Such As: Idimox 250 Tab., Remox 250mg, Dynamox 250
Cap., Moxybiotic 250 Tab., etc.
17
CAPS/TAB – ANTIBIOTICS
Amoxycillin Caps/Tab. 500mg.
Such As: Idimox 500 Tab., Delamin 500mg, Mormox 500
Cap., Amoxil 500 Cap., etc.
18
SYRUP/SUSPENSION – ANTIBIOTICS
Amoxycillin Syp/Susp. 250mg./5ml.
Such As: Moxired Syp., Mox 250 Syp., Elmox 250 Syp., etc.
19
CAPS/TAB - BETA BLOCKERS
Atenolol Caps/Tab. 50mg.
Such As: Aten 50mg. Tab., Cardinol Tab., Atekind 50 Tab.,
Telol 50 Tab., etc.
20
CAPS/TAB - BETA BLOCKERS
Atenolol Caps/Tab. 100mg.
Such As: Beta 100mg, Atcardil 100mg, Atelol 100 Tab.,
Partenol 100 Tab., etc.
21
CAPS/TAB - HYPOLIPIDAEMIC DRUG
Atorvastatin Caps/Tab. 10mg.
Such As: ATV 10 Tab., Lipicure TZ Tab., Relextor 10 Tab.,
Rosustat 10 Tab., etc.
22
CAPS/TAB - HYPOLIPIDAEMIC DRUG
Atorvastatin Caps/Tab. 20mg.
Such As: Atorin 20 Tab., Zimostat 20 Tab., Stator 20mg.
Tab., Avas 20mg. Tab., etc.
23
CAPS/TAB - HYPOLIPIDAEMIC DRUG
Atorvastatin Caps/Tab. 40mg.
Such As: Stator 40mg, Tonact 40mg, Aztor 40 Tab., Storvas
40 Tab., etc.
24
CAPS/TAB – ANTIBIOTICS
Azithromycin Caps/Tab. 250mg.
Such As: A Thromicin 250 CapTab., Benzithro 250 CapTab.,
Rowin 250 Tab., Aziwok 250 Tab., etc.
25
CAPS/TAB – ANTIBIOTICS
Azithromycin Caps/Tab. 500mg.
Such As: A Thromicin 500 CapTab., Rowin 500 Tab.,
Zithromax Tab., Azyxin 500 Tab., etc.
26
SYRUP/SUSPENSION – ANTIBIOTICS
Azithromycin Syp/Susp. 200mg./5ml.
Such As: Bactrocin Susp., Azest Susp., Azysafe Susp.,
Azibact Syp., etc.
27
LOTION - SCABICIDES/ PEDICULOCIDES
& ANTI-DANDRUFF
Benzyl Benzoate Lotion 25% -100ml.
28
CAPS/TAB – MINERALS
Calcium Carbonate Caps/Tab. 250mg.
Such As: Calcium Sandoz 250mg), Bonycal 250mg, Intacia
250mg., Cal D 250 Tab., etc.
29
CAPS/TAB – MINERALS
Calcium Carbonate Caps/Tab. 500mg.
Such As: Bonycal 500mg, Calcium Sandoz 500mg, Cal D
500 Tab., Rocal 500 Tab., etc.
30
CAPS/TAB - ALLERGIC DISORDERS
Cetirizine Caps/Tab. 10mg.
Such As: Cetzine 10mg. Tab., Defal 10mg. Tab., Idicet
10mg. Tab., Cetrizine 10 Tab., etc.
31
SYRUP/SUSPENSION - ALLERGIC
DISORDERS
Cetirizine Syp/Susp. 5mg./5ml. -60ml.
32
CAPS/TAB - ANTI-MALARIAL
Chloroquine Caps/Tab. 150mg.
Such As: Lariago 250mg, Chloroquin 250mg, etc.
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eC Agreement (26.11.19)
33
SYRUP/SUSPENSION - ANTIMALARIAL
Chloroquine Syp/Susp. 50mg./5ml.
Such As: Hiquine Syp., Mediquine Syp., etc.
34
CAPS/TAB - ALLERGIC DISORDERS
Chlorpheniramine Maleate Caps/Tab. 4mg.
Such As: Cadistin 4mg Tab., CPM 4mg Tab., Piriton 4mg.
Tab., Chlorphenermine 4mg. Tab., etc.
35
SYRUP/SUSPENSION - ALLERGIC
DISORDERS
Chlorpheniramine Maleate Syp/Susp.
2mg./5ml.
Such As: Polaramine 50ml, Trigenic Drops 15ml, etc.
36
CAPS/TAB – VITAMINS
Cholecalciferol (Vit. D3) Caps. 1000IU.
Such As: Uprise D3 Caps., Romical Plus., etc.
37
SACHET – VITAMINS
Cholecalciferol (Vit. D3) Sachet 60,000IU.
Such As: Mcirol 60000IU. Sachet, Calcirol 1gm, D3 Up.
Sachet., Caldikind Sachet, etc.
38
CAPS/TAB – ANTIBIOTICS
Ciprofloxacin Caps/Tab. 250mg.
Such As: Ciporal 250 Tab., Ciprobid 250mg, Ciproplus 250
Tab., Zoxan 250 Tab., etc.
39
CAPS/TAB – ANTIBIOTICS
Ciprofloxacin Caps/Tab. 500mg.
Such As: Cifran 500 Tab., Ciplox 500mg. Tab., Ciporal 500
Tab., Ceplox 500 Tab., etc.
40
SYRUP/SUSPENSION – ANTIBIOTICS
Ciprofloxacin Syp/Susp. 250mg./5ml.
Such As: Ciprodex 60ml., Suncip 50ml., Ziprex 60ml., Rebac
Syp., etc.
41
EYE DROPS – EYE
Ciprofloxacin Eye/Ear Drop 0.3%
Such As: Zoxan EyeDrop -5ml., Cifran Eye/Ear Drop,
Ciporal Eye/Ear Drop -5ml., Ciprowin Eye/Ear Drop, etc.
42
CREAM/OINT/GEL – EYE
Ciprofloxacin Eye Cream/Oint/Gel.
0.3%
Such As: Ciplox Eye Oint. -5gm., Ciprofloxacin Eye Oint.
0.3%, Daplox Eye Oint. -5gm., Adiflox Eye Oint., etc.
43
CAPS/TAB - LOCAL DRUGS FOR
VAGINA AND CERVIX
Clotrimazole VaginalTab. 100mg.
Such As: Clogen 100mg, Nuforce V6 100mg, Clotromin V6
Tab., Fungnil V 100 Tab., etc.
44
CREAM/OINT/GEL - TOPICAL
ANTIFUNGAL
Clotrimazole Cream/Oint/Gel. 1%
Such As: Canazole Skin Cream 15gm, Surfaz Skin Cream
15gm, Ctzole Cream, Imidil Plus Cream, etc.
45
EAR DROPS – EAR
Clotrimazole EarDrop 1%
Such As: Surfaz EarDrop -10ml., , , , etc.
46
CAPS/TAB – ANTIBIOTICS
Cloxacillin Caps/Tab. 250mg.
Such As: Ampoxin 250mg, Clopen 250 Cap., Neoclox 250
Cap., Klox 250 Cap., etc.
47
CAPS/TAB – ANTIBIOTICS
Cloxacillin Caps/Tab. 500mg.
Such As: Nodimox Plus 500mg, Klox 500 Cap., Neoclox 500
Cap., Clopen 500 Cap., etc.
48
SYRUP/SUSPENSION – ANTIBIOTICS
Cloxacillin Dry Syp/Susp. 125mg./5ml.
Such As: Maxclox Dry Syp., Polyklox Dry Syp., Clopen Syp.,
Klox Syp., etc.
49
CAPS/TAB – ANTIBIOTICS
Cotrimoxazole (Trimethoprim 80mg.
and Sulphamethoxazole 400mg.) Caps/Tab.
Such As: Septran Tab., etc.
50
CAPS/TAB – ANTIBIOTICS
Cotrimoxazole (Trimethoprim 160mg.
and Sulphamethoxazole 800mg.) Caps/Tab.
Such As: Duocidal DS Tab., Sepmax DS Tab., etc.
51
SYRUP/SUSPENSION - ANTIBIOTICS
Cotrimoxazole Syp/Susp.- Trimethoprim 40mg.,
Sulphamethoxazole
200mg.
(Per
5ml)
-
Syp/Susp. -60ml.
Such As: Methoxaprim Susp. -60ml., etc.
52
CAPS/TAB – CORTICOSTEROIDS
Dexamethasone Caps/Tab. 0.5mg.
Such As: Dexacip 0.5mg, Decicort 0.5mg, Wymesone
0.5mg., Dexasone 0.5mg., etc.
53
CAPS/TAB - NON-OPOID ANALGESIC
Diclofenac Sodium Caps/Tab. 50mg.
Such As: Idinac 50mg. Tab., Voveran 50 Tab., Haloran 50
Tab., Runac 50 Tab., etc.
54
INJ - NON-OPOID ANALGESIC
Diclofenac Sodium Inj. 25mg./ml.
Such As: Dicloveron 25 Inj. -3ml., Dicolab 25 Inj. -3ml.,
Dicor 25 Inj. -3ml., Voveran Inj. -3ml., etc.
55
CAPS/TAB - ANTISPASMODIC/DRUGS
MODIFYING INTESTINAL MOTILITY
Dicyclomine HCl. Caps/Tab. 10mg.
Such As: Diospas Tab. 10mg, Efespas Tab. 10mg, etc.
56
SYRUP/SUSPENSION - ANTI-
SPASMODIC/DRUGS MODIFYING
INTESTINAL MOTILITY
Dicyclomine HCl. Syp/Susp. 10mg./5ml. -30ml.
Such As: Meftal Spas Drops 10ml, Cyclopam Susp 30ml,
Cymotin Drops., etc.
57
CAPS/TAB - ANTI EMETICS
Domperidone Caps/Tab. 10mg.
Such As: Domstal 10 Tab., Redom 10 Tab., Nudom 10 Tab.,
Vomidon 10 Tab., etc.
58
SYRUP/SUSPENSION - ANTI EMETICS
Domperidone Syp/Susp. 1mg./ml. 60ml.
Such As: Domstal 30ml, Vomistop 30ml, Tridom 30ml.,
Normetic 30ml., etc.
59
CAPS/TAB – ANTIBIOTICS
Doxycycline Caps/Tab. 100mg.
60
SYRUP/SUSPENSION – ANTIBIOTICS
Doxycycline Dry Syp/Susp. 50mg./5ml.
Such As: Doxicip 10ml, Minicycline 30ml, etc.
61
CAPS/TAB -
HAEMATINICS/ERYTHROPOIETI
CS
Ferrous Salt Eqv. To Elem. Iron 60mg.
Caps/Tab.
62
SYRUP/SUSPENSION - HAEMATINICS/
ERYTHROPOIETICS
Colloidal Iron Eqv. To Elem. Iron
250mg., Folic Acid 500mg., Vit. B12
5mcg. (Per ml.) -Drops
Such As: Tonoferon Drops, Feritin 150ml, etc.
63
CAPS/TAB - VASO
CONSTRICTOR/MIGRAINE
Flunarizine Caps/Tab. 5mg.
Such As: Migrazine 5mg, Migarid 5mg, Nariz 5mg. Tab.,
Flunarin 5mg. Tab., etc.
64
CAPS/TAB - VASO
CONSTRICTOR/MIGRAINE
Flunarizine Caps/Tab. 10mg.
Such As: Fluzin Tab., Migazin Tab., Nariz 10mg. Tab.,
Flunarin 10mg. Tab., etc.
65
CAPS/TAB – VITAMINS
Folic Acid Caps/Tab. 5mg.
Such As: Folitab 5mg. Tab., Folvite 5 Tab., Facitab 5mg.,
Neofol 5mg., etc.
66
CREAM/OINT/GEL - ANTI INFECTIVE
PREPARATIONS
Framycetin Sulph. Cream/Oint/Gel. 1%
Such As: Soframycin Cream -30gm., Soframycin -20gm.,
etc.
12
eC Agreement (26.11.19)
67
CAPS/TAB – DIURETICS
Furosemide Caps/Tab. 40mg.
Such As: Frunex Tab., Lasix 40 Tab., Lasiwin Tab., etc.
68
SYRUP/SUSPENSION - URINARY
SYSTEM
Furosemide Syp/Susp. 10mg./ml.
Such As: Furaped Syp. 10mg./ml. -30ml., Fursimide Syp. -
30ml., etc.
69
INJ – DIURETICS
Furosemide Inj. 10mg./ml.
Such As: Fru 20 Inj. -2ml., Frunex Inj. -2ml., Frusix Inj. 2ml.,
Lasix 10mg. Inj. -2ml., etc.
70
EYE DROPS – EYE
Gentamicin Eye/Ear Drop 0.3%
Such As: Genteye Eye/ear Drop, Merigenta Eye/Ear Drop,
Norget EyeDrop, Gentalab Drop, etc.
71
CAPS/TAB - HYPO-GLYCAEMICS
Glimepiride Caps/Tab. 1mg.
Such As: Idiglim 1 Tab., Zimeprid 1 Tab., Prichek 1 Tab.,
Ziglim 1 Tab., etc.
72
CAPS/TAB - HYPO-GLYCAEMICS
Glimepiride Caps/Tab. 2mg.
Such As: Bryl 2 Tab., Rhypiride 2 Tab., Zimeprid 2 Tab.,
Ziglim 2 Tab., etc.
73
CAPS/TAB – DIURETICS
Hydrochlorothiazide Caps/Tab.
12.5mg.
Such As: Aquazide 12.5mg. Tab., Xenia 12.5mg. Tab.,
Hydrazide 12.5 Tab., Hydride 12.5 Tab., etc.
74
CAPS/TAB – DIURETICS
Hydrochlorothiazide Caps/Tab. 25mg.
Such As: Bpzide 25 Tab., Xenia 25mg. Tab., Bezide 25mg.
Tab., Hydrazide 25 Tab., etc.
75
CAPS/TAB - ANTISPASMODIC/DRUGS
MODIFYING INTESTINAL
MOTILITY
Hyoscine Butyl Br. Caps/Tab. 10mg.
Such As: Decolic Tab., Buscopan 10 Tab., Hyoswift 10 Tab.,
Hyospan Tab., etc.
76
CAPS/TAB - NON-OPOID ANALGESIC
Ibuprofen Caps/Tab. 200mg.
Such As: Brufen 200mg. Tab., IBF 200mg. Tab., Ibupal 200
Tab., Rebufen 200 Tab., etc.
77
CAPS/TAB - NON-OPOID ANALGESIC
Ibuprofen Caps/Tab. 400mg.
Such As: Brufen 400mg. Tab., IBF 400mg. Tab., Ibupal 400
Tab., Rebufen 400 Tab., etc.
78
SYRUP/SUSPENSION - NONOPOID
ANALGESIC
Ibuprofen Syp/Susp. 100mg./5ml. 60ml.
Such As: Brufen Susp. 100mg./5ml. -60ml., Gesic Susp. -
60ml., Ibuswiss Susp. -60ml., Ibugesic 60ml., etc.
79
CAPS/TAB - ANTI-ANGINAL DRUGS
Iso Sorbide Dinitrate Tab. 5mg.
Such As: Anzidin 5 Tab., Isordil 5 Tab., Sorbitrate 5mg.
Tab., Ditrate 5mg., etc.
80
CAPS/TAB - ANTI-ANGINAL DRUGS
Iso Sorbide Dinitrate Tab. 10mg.
Such As: Anzidin 10 Tab., Sorbitrate 10mg. Tab., Isordil 10
Tab., Ditrate 10mg., etc.
81
CAPS/TAB - THYROID AND ANTI
THYROID DRUGS
Thyroxine Sodium Caps/Tab.
12.5mcg.
Such As: Thyrox 12.5mcg , Thyronorm 12.5mcg, etc.
82
CAPS/TAB - THYROID AND ANTI
THYROID DRUGS
Thyroxine Sodium Caps/Tab. 25mcg.
Such As: Eltroxin 25mcg. Tab., Thyrox Tab. 25mcg.,
Thyrowin 25mcg., Lethyrox 25mcg., etc.
83
CAPS/TAB - THYROID AND ANTI
THYROID DRUGS
Thyroxine Sodium Caps/Tab. 50mcg.
Such As: Thyrox Tab. 50mcg., Eltroxin 50mcg. Tab.,
Thyrochek 50 Tab., Lethyrox 50mcg., etc.
84
CAPS/TAB - THYROID AND ANTI
THYROID DRUGS
Thyroxine Sodium Caps/Tab. 75mcg.
Such As: Eltroxin 75mcg. Tab., Lethyrox 75mcg, Thyroup
75mcg., Thyrofilt 75mcg. Tab., etc.
85
CAPS/TAB - THYROID AND ANTI
THYROID DRUGS
Thyroxine Sodium Caps/Tab. 62.5mcg
Such As: Thyronorm Tab. 62.5mcg, etc.
86
CAPS/TAB - THYROID AND ANTI
THYROID DRUGS
Thyroxine Sodium Caps Tab 88mcg
Such As: Lethyrox Tab. 88mcg., etc.
87
CAPS/TAB - THYROID AND ANTI
THYROID DRUGS
Thyroxine Sodium Caps/Tab. 100mcg.
Such As: Thyrox Tab. 100mcg., Eltroxin 100mcg. Tab.,
Thyrochek 100 Tab., Lethyrox 100mcg, etc.
88
CAPS/TAB - THYROID AND ANTI
THYROID DRUGS
Thyroxine Sodium Caps/Tab. 125mcg.
Such As: Eltroxin 125mcg, Thyronorm 125mcg, Thyrox Tab.
125mcg., Thyrosec Tab. 125mcg., etc.
89
CAPS/TAB - THYROID AND ANTI
THYROID DRUGS
Thyroxine Sodium Caps/Tab. 150mcg.
Such As: Thyronorm 150mcg, Thyrox 150mcg, etc.
90
CAPS/TAB – ANTHELMINTICS
Mebendazole Caps/Tab. 100mg.
Such As: Idibend 100mg. Tab., Mebex Tab. 100mg.,
Mebazole 100 Tab., Mendazole 100 Tab., etc.
91
SYRUP/SUSPENSION - ANTHELMINTICS
Mebendazole Syp/Susp. 100mg./5ml.
Such As: Mebex Susp. 30ml, Idibend Susp., Nuzole Susp.,
Wormin Susp., etc.
92
CAPS/TAB - HYPO-GLYCAEMICS
Metformin Caps/Tab. 500mg.
Such As: Glyciphage (500 mg), Glycomet 500mg, Serformin
500 Tab., Metlife 500 Tab., etc.
93
CAPS/TAB - HYPO-GLYCAEMICS
Metformin Caps/Tab. 750mg.
94
CAPS/TAB - HYPO-GLYCAEMICS
Metformin Caps/Tab. 1gm.
Such As: Glycomet 1000mg, Glyrep 1000 Tab., Bigesens
1000 Tab., Metsafe 1000 Tab., etc.
95
CAPS/TAB - HYPO-GLYCAEMICS
Metformin SRCaps/Tab. 500mg.
Such As: Gluconorm SR 500mg, Glyciphage SR 500mg,
Forminal SR 500 Tab., Glyrep XL 500 Tab., etc.
96
CAPS/TAB - HYPO-GLYCAEMICS
Metformin SRCaps/Tab. 750mg.
97
CAPS/TAB - HYPO-GLYCAEMICS
Metformin SR Caps/Tab. 1gm.
Such As: Forminal 1000 SRTab., Glycomet 1gm. SRTab.,
Glyzet SRTab., Zoform SR 1000 Tab., etc.
98
CAPS/TAB – ANTIBIOTICS
Metronidazole Caps/Tab. 200mg.
Such As: Flagyl 200 Tab., Metrogyl 200 Tab., Metgyl 200
Tab., Ambizol 200 Tab., etc.
99
CAPS/TAB – ANTIBIOTICS
Metronidazole Caps/Tab. 400mg.
Such As: Flagyl 400 Tab., Metrogyl 400 Tab., Metgyl 400
Tab., Ambizol Forte Tab., etc.
100
SYRUP/SUSPENSION – ANTIBIOTICS
Metronidazole Syp/Susp. 200mg./5ml.
Such As: Metrazole Susp., Metrogyl Paediatric Syp.,
Metrogyl Susp. -60ml., Metron 200 Susp., etc.
13
eC Agreement (26.11.19)
101
CAPS/TAB – ANTIBIOTICS
Nitrofurantoin Caps/Tab. 100mg.
Such As: Furadantin 100mg. Caps., Urifast Caps., Martifur
100 Tab., Urinif 100 Tab., etc.
102
SYRUP/SUSPENSION – ANTIBIOTICS
Nitrofurantoin Syp/Susp. 25mg./5ml.
103
SACHET - REHYDRATION SALTS
ORS (WHO Formula)- Sodium
Chloride 2.6gm., Potasium Chloride
1.5gm., Sodium Citrate 2.9gm.,
Dextrose (Anhydrous) 13.5gm. Sachet
Such As: Jeevanjal Sachet, ORS Powder, etc.
104
CAPS/TAB - NON-OPIOID ANALGESIC
Paracetamol Caps/Tab. 500mg.
Such As: Crocin 500 Tab., Calpol 500 Tab., Larkin 500 Tab.,
Paracin 500 Tab., etc.
105
CAPS/TAB - NON-OPIOID ANALGESIC
Paracetamol Caps/Tab. 650mg.
Such As: Febrex Tab. 650mg., Dolo 650 Tab., Mormol 650
Tab., Metaplus 650 Tab., etc.
106
SYRUP/SUSPENSION - NONOPIOID
ANALGESIC
Paracetamol Syp/Susp. 125mg./5ml. 60ml.
Such As: Idimol Syp. -60ml. -IDPL, Pyrexil Syp. -60ml. RDPL,
P 125 Syp., Malidens Syp., etc.
107
SYRUP/SUSPENSION - NONOPIOID
ANALGESIC
Paracetamol Syp/Susp. 150mg./ml. 15ml.
Such As: Paracip Paed. Drops 150mg./ml. -15ml. , Teplow
Syp. 60ml., Medimol Drops., Pyrigesic Drops., etc.
108
CAPS/TAB - ANTI CONVULSANTS
Phenytoin Sodium Caps/Tab. 50mg.
Such As: Epsolin 50mg, C Toin 50mg, Atoin 50 Tab., Stoin
50 Tab., etc.
109
CAPS/TAB - ANTI CONVULSANTS
Phenytoin Sodium Caps/Tab. 100mg.
Such As: Ctoin 100 Tab., Phenytos Tab., Phentium Tab.,
Eptoin 100 Tab., etc.
110
CAPS/TAB - ANTI CONVULSANTS
Phenytoin Sodium ERCaps/Tab. 300mg.
Such As: Epipres ER (300 mg), C Toin ER (300 mg), Epsolin
ER 300 Tab., etc.
111
CAPS/TAB - ANTI CONVULSANTS
Phenytoin Sodium Caps/Tab. 300mg.
Such As: Epsolin 300mg, Stoin 300mg, Phalin 300 Tab., etc.
112
SYRUP/SUSPENSION - ANTI
CONVULSANTS
Phenytoin Syp/Susp. 30mg./5ml.
Such As: Eptoin Syp., etc.
113
SYRUP/SUSPENSION - ANTI
CONVULSANTS
Phenytoin Sodium Syp/Susp. 25mg./ml. -
100ml.
114
CAPS/TAB – CORTICOSTEROIDS
Prednisolone Caps/Tab. 5mg.
Such As: Wysolone 5mg. Tab., Solon 5 Tab., Pred 5 Tab.,
Novapred 5 Tab., etc.
115
CAPS/TAB – CORTICOSTEROIDS
Prednisolone Caps/Tab. 10mg.
Such As: Delsone 10 Tab., Nephcorte 10 Tab., Pred 10 Tab.,
Novapred 10 Tab., etc.
116
CAPS/TAB – CORTICOSTEROIDS
Prednisolone Caps/Tab. 20mg.
Such As: Novapred 20 Tab., Acticort 20 Tab., Pednisol 20
Tab., Monocortil 20 Tab., etc.
117
SYRUP/SUSPENSION -
CORTICOSTEROIDS
Prednisolone Syp/Susp. 5mg.
Such As: Omnacortil Srup, Elpred 60ml., Nucort P Syp.,
Kidpred Syp. 60ml., etc.
118
SYRUP/SUSPENSION -
CORTICOSTEROIDS
Prednisolone Syp/Susp. 15mg./5ml.
Such As: Omnacortil Forte Syp. -60ml., Predon Forte Syp.,
Besone Forte Syp., etc.
119
CAPS/TAB - ANTI-MALARIAL
Primaquine Caps/Tab. 2.5mg.
Such As: Leoprime Kid 2.5 Tab., PMQ 2.5 Tab., Malirid DT
2.5 Tab., etc.
120
CAPS/TAB - ANTI-MALARIAL
Primaquine Caps/Tab. 7.5mg.
Such As: Malarid Tab., Primal 7.5 Tab., Pquine 7.5 Tab.,
Primax 7.5 Tab., etc.
121
CAPS/TAB - ANTI-MALARIAL
Primaquine Caps/Tab. 15mg.
Such As: Rhyquin 15 Tab., Primax 15 Tab., Pimaquin 15
Tab., Leoprime Forte 15 Tab., etc.
122
CAPS/TAB - BETA BLOCKERS
Propranolol HCl. Caps/Tab. 10mg.
Such As: Ponol Tab. 10mg., Betabloc 10 Tab., Corbeta 10
Tab., Peelar 10 Tab., etc.
123
CAPS/TAB - ANTIHYPERTENSIVES
Ramipril Caps/Tab. 2.5mg.
Such As: Ramichek 2.5 Tab., Raminor 2.5 Tab., Rampiwin
2.5 Tab., Saface 2.5 Tab., etc.
124
CAPS/TAB - ANTIHYPERTENSIVES
Ramipril Caps/Tab. 5mg.
Such As: Ramipres 5 Tab., Cardace 5 Tab., Hopace 5 Tab.,
Saface 5 Tab., etc.
125
CAPS/TAB - H2 BLOCKERS AND ULCER
HEALING DRUGS
Ranitidine Caps/Tab. 150mg.
Such As: Idiran 150 Tab., Rantac 150mg. Tab., Renit 150
Tab., Lantac 150 Tab., etc.
126
SYRUP/SUSPENSION - H2 BLOCKERS
AND ULCER HEALING DRUGS
Ranitidine Syp/Susp. 75mg./5ml.
Such As: Rantac Syp. -30ml., Rantac Syp. -100ml., etc.
127
CAPS/TAB – BRONCHODILATORS
Salbutamol Caps/Tab. 2mg.
Such As: Salmaplon 2 Tab., Salbetol Tab. 2mg., Brosol 2
Tab., Asmanil 2 Tab., etc.
128
CAPS/TAB – BRONCHODILATORS
Salbutamol Caps/Tab. 4mg.
Such As: Asthalin Tab. 4mg., Salbetol Tab. 4mg., Salmaplon
4 Tab., Brosol 4 Tab., etc.
129
SYRUP/SUSPENSION -
BRONCHODILATOR
Salbutamol Syp/Susp. 2mg./5ml.
Such As: Asthawin Syp. -100ml., Medisal Syp. -100ml.,
Rhydastha 2 Syp. -100ml., Salbugal Syp. -100ml., etc.
130
INHALER – INHALERS
Salbutamol Inhaler 100mcg.
Such As: Asthalin 100mcg. Inhaler, Bronkonat 100mcg.
Inhaler, Vent Inhaler 100mcg. Inhaler, Derihaler 100mcg.
Inhaler, etc.
131
CREAM/OINT/GEL - ANTI INFECTIVE
PREPARATIONS
Silver Sulphadiazine Cream/Oint/Gel. 1%
Such As: Silvirin Cream 1% -20gm., Silvindon Cream 1% -
20gm., Waifel Cream 1% -20gm., Silvolar Cream 1% 25gm.,
etc.
132
CAPS/TAB - ANTI CONVULSANTS
Sodium Valproate Caps/Tab. 200mg.
Such As: Valate 200 Tab., Velze 200 Tab., Epival EC 200
Tab., Torvate 200 Tab., etc.
133
CAPS/TAB - ANTI CONVULSANTS
Sodium Valproate and Valproic Acid Caps/Tab.
300mg.
Such As: Torvate 300 Tab., Valtec 300 Tab., Velze 300 Tab.,
Napilex 300 Tab., etc.
14
eC Agreement (26.11.19)
134
CAPS/TAB - ANTI CONVULSANTS
Sodium Valproate Caps/Tab. 500mg.
Such As: Encorate 500mg. Tab., Epilex 500 Tab., Torvate
500 Tab., Valprol EC 500 Tab., etc.
135
CAPS/TAB - ANTI CONVULSANTS
Sodium Valproate and Valproic Acid CR
Caps/Tab. 300mg.
Such As: Valprid CR Tab. 300mg., Encorate Chrono CR
300mg, Valcot CR 300mg, Valric CR 300 Tab., etc.
136
CAPS/TAB – ANTI CONVULSANTS
Sodium Valproate and Valproic Acid
CR Caps/Tab. 500mg.
Such As: Valprid CRTab. 500mg., Valpin 500 CRTab., Vat
CRTab. 500mg., Valate Chrono 500 CRTab., etc.
137
SYRUP/SUSPENSION - ANTI
CONVULSANTS
Sodium Valproate Syp/Susp. 200mg./5ml.
Such As: Valate Syp. -100ml., Valparin 200 Syp. -100ml.,
Valpor Syp. -100ml., Encorate 200 Syp., etc.
138
CAPS/TAB – DIURETICS
Spironolactone Caps/Tab. 25mg.
Such As: Aldactone 25mg. Tab., etc.
139
CAPS/TAB – DIURETICS
Spironolactone Caps/Tab. 50mg.
Such As: Aldactone 50mg. Tab., etc.
140
EYE DROPS – EYE
Sulphacetamide EyeDrop 10%
Such As: Albucid 10% Eye Drops, Bleph 10% Eye Drop,
Suncetamide 10% Eye Drop, Optacid 10% Eye Drop, etc.
141
EYE DROPS – EYE
Sulphacetamide EyeDrop 15%
142
VACCINE – VACCINE
Vaccine - Tetanus Toxoid (Adsorbed) Inj. -0.5
ml.
Such As: Bett Inj. -0.5ml., Tetvac vaccine, etc.
143
CAPS/TAB - HAEMOSTATICS/
COAGULANTS
Tranexamic Acid Caps/Tab. 500mg.
Such As: Trasmic 500mg. Tab., Trasmic Tab., Xamic 500
Tab., Texakind 500 Tab., etc.
144
CAPS/TAB – VITAMINS
Vit. A Caps. 5000IU.
145
CAPS/TAB – VITAMINS
Vit. A Caps. 50000IU.
146
CAPS/TAB – VITAMINS
Vit. A Caps. 100000IU.
147
SYRUP/SUSPENSION – VITAMINS
Vit. A Syp/Susp. 100000IU./ml.
148
NOSE DROPS – NOSE
Xylometazoline NasalDrop 0.05%
Such As: Cirovin 0.05 NasalDrop, Noxyvin 0.05%
NasalDrop, Orinase P NasalDrop, Otrivin Paed NasalDrop,
etc.
149
NOSE DROPS – NOSE
Xylometazoline NasalDrop 0.1%
Such As: Nasibest NasalDrop, Noxyvin 0.1% NasalDrop,
Orinase 0.1% NasalDrop, Xylomet NasalDrop, etc.
150
SYRUP/SUSPENSION - ANTITUSSIVE
Cough Syp/Susp.- Dextromethorphan
10mg., Phenylpropanolamine 12.5mg.,
Guaiphenesin 50mg. Syp/Susp. -100ml.
Such As: Expect D Cough Syp. -100ml., etc.
151
SYRUP/SUSPENSION - ANTITUSSIVE
Cough Syp/Susp.- Dextromethorphan
Hbr. 10mg., Chlorpheniramine
Maleate 4mg.,
Phenylpropylamine12.5mg., Guaiphenesin
100mg. (per 5ml.) Syp/Susp. -100ml.
Such As: Aldex Syp. -100ml., etc.
152
SYRUP/SUSPENSION - ANTITUSSIVE
Cough Syp/Susp.- Dextromethorphan
HBr. 10mg., Triprolidine HCl. 1.25mg.,
Phenylpropanolamine 12.5mg. (per 5ml.) -
Syp/Susp. -100ml.
Such As: Actifed DM Syp. -100ml., etc.
153
SYRUP/SUSPENSION - ANTITUSSIVE
Cough Syp/Susp.- Noscapine 1.83mg.,
Citric Acid 5.8mg., Ammonium Chloride 7mg.,
Sodium Citrate 0.67mg. (per ml.) -Syp/Susp.
Such As: Hi Scopine Paediatric Syp., etc.
154
SYRUP/SUSPENSION - ANTITUSSIVE
Cough Syp/Susp.- Noscapine 15mg.,
Chlorpheniramine Meleate 2.5mg.,
Guaiphenesin 100mg., Sodium Citrate 60mg. -
Syp/Susp.
Such As: Apdyl Syp., Cemadil G Syp., Himaleate Syp., etc.
155
SYRUP/SUSPENSION - ANTITUSSIVE
Cough Syp/Susp.- Noscapine 7mg.,
Chlorpheniramine Maleate 2mg.,
Ammonium Chloride 28mg., Sodium Citrate
3.25mg. (per 5ml.) -Syp/Susp.
-100ml.
Such As: Coscopin Linctus Syp. -100ml., etc.
156
SYRUP/SUSPENSION - ANTITUSSIVE
Paediatric Cough Syp/Susp.- Noscapine
1.83mg., Sodium Citrate 0.67mg., Ammonium
Chloride 7mg. (per 5ml.) -Syp/Susp. -50ml.
Such As: Conscopin Paed Syp. -50ml., etc.
157
SYRUP/SUSPENSION - ANTITUSSIVE
Paediatric Cough Syp/Susp.-
Promethazine HCl. 1.5mg., Pholcodine 1.5mg.
(per 5ml.) Syp/Susp.
Such As: Tixylix Cough Linctus Syp., Coscopin Paediatric
Syp. -50ml., etc.
158
SYRUP/SUSPENSION -
BRONCHODILATOR
Bronchodilator Syp/Susp.- Salbutamol
2mg., Ambroxol HCl. 3mg.,
Guaiphenesin 100mg., Menthol 5mg.
(per 5ml.) -Syp/Susp. -100ml.
Such As: Cofsol Syp. -100ml., etc.
159
SYRUP/SUSPENSION -
BRONCHODILATOR
Bronchodilator Syp/Susp.- Salbutamol 2mg.,
Bromhexine 4mg. (per 5ml.) Syp/Susp. -60ml.
Such As: Salmodil Bronchodilator Cough Syp. -60ml., etc.
160
SYRUP/SUSPENSION -
BRONCHODILATOR
Bronchodilator Syp/Susp.- Salbutamol 2mg.,
Guaiphenesin 100mg. (per ml.) -Syp/Susp. -
100ml.
Such As: Asthalin EXP Syp. -100ml., etc.
161
SYRUP/SUSPENSION -
BRONCHODILATOR
Bronchodilator Syp/Susp.-
Terbutaline 1.25mg., Ambroxol HCl.
Such As: Arcuf plus Syp. -100ml., etc.
15
eC Agreement (26.11.19)
15mg., Guaiphenesin 50mg. (per 5ml.) -
Syp/Susp. -100ml.
162
SYRUP/SUSPENSION -
BRONCHODILATOR
Bronchodilator Syp/Susp.- Terbutaline
1.25mg., Etophylline
50mg. (per 5ml.) -Syp/Susp. -100ml.
Such As: Etolin PD Syp. -100ml., etc.
163
SYRUP/SUSPENSION -
BRONCHODILATOR
Bronchodilator Syp/Susp.- Terbutaline 2.5mg.,
Bromhexine 8mg., Guaiphenesin 100mg.,
Menthol 1mg. (Per 10ml.) -Syp/Susp. -100ml.
Such As: Mucostop Syp. -100ml., etc.
164
SYRUP/SUSPENSION -
BRONCHODILATOR
Bronchodilator Syp/Susp.-
Terbutaline Sulph. 1.25mg., Ambroxol HCl.
15mg., Guaiphenesin 50mg. (per 5ml.) -
Syp/Susp. -100ml.
Such As: Suprivent A Syp. -100ml., etc.
165
SYRUP/SUSPENSION -
BRONCHODILATOR
Bronchodilator Syp/Susp.-
Terbutaline Sulph. 1.25mg., Ambroxol HCl.
30mg., Guaiphenesin 50mg.,
Menthol 0.5mg. (per 5ml.) -Syp/Susp.
Such As: Ambrolite + S Syp. -100ml., Zen Expectorant Syp. -
100ml., etc.
166
SYRUP/SUSPENSION -
BRONCHODILATOR
Bronchodilator Syp/Susp.- Terbutaline Sulph.
1.25mg.,
Bromhexine 400mg., Guaiphenesin 50mg.,
Menthol 2.5mg. (per 5ml.) Syp/Susp. -100ml.
Such As: Chemidrex E Syp. -100ml., etc.
167
SYRUP/SUSPENSION -
BRONCHODILATOR
Bronchodilator Syp/Susp.-
Terbutaline Sulph. 4mg., Bromhexine
HCl. 8mg., Guaiphenesin 200mg. (Per 10ml.) -
Syp/Susp.
Such As: Bromo GX Syp. -100ml., etc.
168
SYRUP/SUSPENSION -
BRONCHODILATOR
Bronchodilator Syp/Susp.-
Terbutaline Sulph. 4mg., Bromhexine HCl.
8mg., Guaiphenesin 200mg. (Per 5ml.) -
Syp/Susp.
Such As: Brotaline Syp., Hextacin Syp., etc.
169
SYRUP/SUSPENSION -
BRONCHODILATOR
Bronchodilator Syp/Susp.-
Theophylline 80mg., Ephedrine HCl.
12mg., Guaiphenesin 50mg., Alcohol 0.55ml.
Absolute Alcohol Content
10.44% -Syp/Susp.
Such As: Hiphylate Elixir Syp., etc.
170
SYRUP/SUSPENSION -
DECONGESTANTS/ANTIHISTAMI
NIC
Chlorpheniramine 4mg.,
Phenylpropanolamine HCl. 15mg.,
Paracetamol 500mg., Caffeine Anhyd.
30mg. (per 5ml.) -Syp/Susp. -60ml.
Such As: Decold Syp. -60ml., etc.
171
SYRUP/SUSPENSION -
DECONGESTANTS/ANTIHISTAMI
NIC
Chlorpheniramine Maleate 2mg.,
Pseudoephedrine HCl. 15mg., Acetaminophen
125mg. (per 5ml.) Syp/Susp. -60ml.
Such As: Cozymin Syp. -60ml., etc.
172
SYRUP/SUSPENSION -
DECONGESTANTS/ANTIHISTAMI
NIC
Cough Syp/Susp.- Diphenhydramine HCl.
Syp/Susp. 12.5mg./5ml. -100ml.
Such As: Benadryl Syp. -100ml., etc.
173
SYRUP/SUSPENSION - EXPECTORANT
Bromhexine Syp/Susp. 4mg./5ml.
Such As: Hibrome Syp. -100ml., Microxine Syp. -100ml.,
Mukotic Syp., Muku Syp. -100ml., etc.
174
SYRUP/SUSPENSION - EXPECTORANT
Cough Expectorant- Ambroxol HCl. 30mg.,
Cetirizine HCl. 2.5mg. (per 5ml.) -Syp/Susp.
Such As: Tuspel PX Syp. -100ml., etc.
175
SYRUP/SUSPENSION - EXPECTORANT
Cough Expectorant- Ambroxol HCl. 30mg.,
Cetirizine HCl. 5mg. (per 5ml.) -Syp/Susp.
Such As: Ambrodex D Syp. -100ml., etc.
176
SYRUP/SUSPENSION - EXPECTORANT
Cough Expectorant- Ambroxol HCl. Syp/Susp.
30mg./5ml.
Such As: Ambrodex D Syp. -100ml., etc.
177
SYRUP/SUSPENSION - EXPECTORANT
Cough Expectorant- Bromhexine
4mg., Cetirizine Dihydrochloride
2.5mg., Phenylephrine 5mg.,
Guaiphenesin 50mg., Menthol 1mg.
(per 5ml.) -Syp/Susp. -100ml.
Such As: Alcodex GC Syp. -100ml., Oxidyne Syp. 100ml.,
etc.
178
SYRUP/SUSPENSION - EXPECTORANT
Cough Expectorant- Bromhexine HCl.
4mg.,Terfenadine 30mg.,
Guaiphenesin 100mg. (per 5ml.) Syp/Susp.
Such As: Alerpect Syp. -100ml., etc.
179
SYRUP/SUSPENSION - EXPECTORANT
Cough Expectorant- Carbinoxamine
Maleate 4mg., Ammonium Chloride 240mg.,
Sodium Citrate 240mg. (per 10ml.) -
Syp/Susp.
Such As: Clistin Expectorant Syp., etc.
180
SYRUP/SUSPENSION -
Cough Expectorant
Such As: Apihist Syp. -100ml., etc.
eDC Agreement Document (26/11/19)
1
(TO BE EXECUTED BY THE SUCCESSFUL PARTICIPANT AT TIME OF AWARD OF CONTRACT)
AGREEMENT BETWEEN ESIC AND DIAGNOSTIC CENTRE
[UNDER MODIFIED INSURANCE MEDICAL PRACTITIONER (mIMP) SCHEME]
(To be executed in Rs 100 Non-Judicial Stamp paper)
THIS AGREEMENT (the “Agreement”) is made and entered on the __________ day of
____________ in the year two thousand and ___________, on the terms and conditions herein
contained:
BY AND BETWEEN
Employees’ State Insurance Corporation (ESIC), represented by Dr. / Mr. / Mrs.
________________________, Age ____, Gender _____, S/O,D/O,W/O_________________,
working as Regional Director/ SRO In-charge, at Employees’ State Insurance Corporation (ESIC)
___________________(place of office with full address), (hereinafter referred to as ‘ESIC’) which
expression shall, unless it be repugnant to the context or meaning thereof, be deemed to mean
and include its successors and assigns) of the ONE PART (FIRST PARTY).
And
Dr. / Mr. / Mrs._____________________, Age ________, Gender _________
S/O,D/O,W/O_________________________
Resident
of
_________________________,
representing __________________________ (Name & address of Diagnostic Centre), designation
/ in the capacity of __________________________ [hereinafter referred to as the ‘empanelled
Diagnostic Centre’ (eDC) under mIMP Scheme] which expression shall, unless it be repugnant to
the context or meaning thereof, be deemed to mean and include its successors and assigns) of
the OTHER PART (SECOND PARTY).
WHEREAS, the Second Party (eDC) has read the terms and condition of this Agreement,
and is willing to be engaged as an empaneled Diagnostic Centre on the terms and conditions,
hereinafter appearing in this agreement and which he/she has signed in token of acceptance of
terms and conditions mentioned therein.
WHEREAS, the empaneled Diagnostic Centre has agreed to provide Medical services to
bonafide ESIC Beneficiaries as per stipulated terms and conditions for upto a period of ________.
WHEREAS, each Party is duly authorized and capable of entering into this Agreement.
NOW, THEREFORE, in consideration of the above recitals, the Parties hereby agree as follows:
a.
TERMS / DURATION /TERMINATION:
i.
The engagement of Second Party as empaneled Diagnostic Centre will be purely
contractual during the period of this contract and shall be valid for initial period of
one year, renewable every year on satisfactory performance services, and
extendable for maximum period of 3 years under same terms and conditions . If
either
party
seeks
to
terminate
this
Agreement,
the
terminating
party must provide 30 days’ notice to the other party or payment @ Rs. 10,000
(Rupees Ten Thousand only) in lieu of the notice period.
eDC Agreement Document (26/11/19)
2
ii.
However, the FIRST PARTY reserves the right to terminate the Contract by giving
notice of Seven days, if the SECOND PARTY is in breach of contract. Also, the FIRST
PARTY is entitled to rescind the contract by reason of SECOND PARTY’s
misrepresentation, undue influence or duress or where some unforeseen event that
may prevent the parties to perform the contract.
iii.
The contract period as mentioned in agreement will commence with effect from the
date of signature by both parties and will be counted only from that date on which
after the execution of this agreement by both parties.
iv.
The Regional Office/DCBO, at the time of empanelment of an eDC shall be tagging an
IMP Clinic so as to help beneficiaries avail services from these eDC. More than one
eDC can be attached to an IMP Clinic or vice versa to bring in ease of service delivery
and competition. There shall be no capping on number of IPFamily units that can be
tagged to any eDC.
b. THE SCOPE OF SERVICES:
The eDC shall provide services to the Beneficiaries and abide by instructions as
specified in “Annexure E” (the “Services”). However, the instructions are liable for
modifications without prior notice.
c. LISTED INVESTIGATIONS:
The SECOND PARTY (eDC) shall provide services for ‘Listed Investigations’ as per
“Annexure C” to the ESI beneficiaries free of cost and get reimbursed from ESIC at flat
____ % discount on the rate specified against the test names as mentioned in
“Annexure C”. These rates shall be valid for one year from the date of award of
contract and shall be subject to modification with the discretion of ESIC after
completion of one year. Prescribed test facilities provided to the ESIC beneficiaries
outside the Specified List (‘Unlisted Tests’) shall be charged from the beneficiaries at
flat ____ % discount on the CGHS specified rates for the CGHS listed investigation as
per (Annexure F), as agreed upon by him and on the basis of quote approved by ESIC.
These rates shall be valid for one year from the date of award of contract and shall be
subject to modification with the discretion of ESIC after completion of one year.
d. OTHER TERMS & CONDITIONS
1. The SECOND PARTY (eDC) agrees to provide diagnostic services to the ESI beneficiaries
against the prescription of Insurance Medical Practitioner (IMP) registered under the
mIMP Scheme.
2. The eDC understands that the Price mentioned against a diagnostic test name on
which the rebate offered in percentage is inclusive of all taxes and duties payable
during the contract period.
3. The eDC should be complying with the statutory rules, regulations and licenses
pertaining to trade, including that of the Clinical Establishments (Registration and
Regulation) Act, 2010 and amendments made thereafter, and submit copies of
relevant document to ESIC.
4. The eDC shall provide cashless services to the ESI Beneficiaries only when the
prescribed investigations are carried out from the ESIC defined ‘Listed’ items
(“Annexure C”) prescribed by the registered IMP Clinic. This amount shall be claimed
at the end of the month from ESIC, for reimbursement.
eDC Agreement Document (26/11/19)
3
5. If ‘Unlisted investigations’ (Tests outside the items Listed/published by ESIC) is
prescribed, the beneficiary shall have either of the two options: (1): To pay from
pocket at the agreed discounted price to avail the diagnostic services from the eDC
and later claim reimbursement from ESIC/DCBO producing copies of bills, proof of
receipt of report and prescription written on the Health Passbook by the registered
doctor; OR, (2): avail these from ESI Hospital, free of cost. This implies that for unlisted
Tests, the eDC shall charge the cost from the patient as per the agreed upon rate
(Discounted on CGHS rate, “Annexure F”) upfront when purchased by the beneficiary
and issue the Bill and capture information in the relevant fields of Mobile App.
6. The eDC shall submit claims to ESIC (DCBO/BO) for the cashless services provided to
the ESI Beneficiaries. Branch Office/DCBO/Regional Office shall reimburse claims
through online method(s), deducting any statutory requirements/taxes, as deemed fit.
7. Non-eligible IP or his family member may be treated as a private patient.
8. The eDC will maintain quality and provide the diagnostic services at all times during
the contract period for uninterrupted provisioning to user and shall conduct the tests
as per prescription and terms written herein.
9. The eDC shall ensure that reagents, kits, films, etc. are available and equipments are
in working conditions. The eDC acknowledges that tampering with prescribed tests
names, test reports and any indulging in any unethical practices is a criminal offence,
and eDC shall be held responsible and accountable for any or all legal consequences.
10. The second party agrees that, in case of failure or refusal by second party to conduct
the tests or provide the services to the Beneficiaries during the contract period, the
contract is liable to be cancelled at his risk and cost and any extra cost involved in
arranging services from alternative source will be recovered from his
subsequent/pending bills. Failure to fulfill the terms of contract may entail for closure
of contract.
11. The eDC undertakes that under any circumstances if his/her license for executing
business is cancelled/ suspended by any authority / Govt., this contract shall stand
terminated automatically.
12. The eDC undertakes that his/her firm is not blacklisted /deregistered currently and has
not been Blacklisted /deregistered by any other Govt. institution/ Organization during
the last three years for any reason including indulging in unethical practices or not
complying with statutory laws.
13. The eDC undertakes that he/she has not been convicted by any court of law in any
matter related to his diagnostic services or on any other grounds.
14. The eDC undertakes that his/her firm is not convicted in an offence under the
prevention of Corruption Act, 1988, or under the Indian Penal Code or any other
15. law for the time being in force, for any cause of life or property or causing a threat to
public health as part of execution of diagnostic services.
e. RESPONSIBILITY OF THE SECOND PARTY:
The First Party (ESIC), in all good faith shall pay remuneration, as defined and as agreed,
to the Second Party, within 15 days of receipt of complete and correct reimbursement
Claim from the Second Party.
eDC Agreement Document (26/11/19)
4
f. INDEPENDENT CONTRACTOR STATUS
The Second Party shall be serving as an independent contractor in providing the Services.
Under this Agreements, the Second Party is neither an employee nor a partner of ESIC.
g. GOVERNING LAW.
The laws of the State of India govern all matters arising out of or relating to this Agreement
and the transactions it contemplates, including, without limitation, its interpretation,
construction, validity, performance, and enforcement.
SIGNATURE OF FIRST PARTY
SIGNATURE OF SECOND PARTY
DATE:
DATE:
PLACE:
PLACE:
WITNESS 1:
WITNESS 2:
NAME:
NAME:
DATE:
DATE:
PLACE:
PLACE:
WITNESS 3:
WITNESS 4:
NAME:
NAME:
DATE:
DATE:
PLACE:
PLACE:
eDC Agreement Document (26/11/19)
5
“ANNEXURE - E”
THE SCOPE OF SERVICES FOR EMPANELLED DIAGNOSTIC CENTRE (eDC)
A. SCOPE OF SERVICES:
1. Diagnostic Centre will download the ESIC “Dhanwantri” mobile app from Google Play store
into an Android smartphone device to log-in with the ESIC issued user credentials (User ID
& Password). The SIM Card of the mobile number registered with ESIC must be in the same
smartphone device where the Mobile App has been downloaded to authenticate user
through OTP.
2. The eDC shall ascertain that the Health Passbook (a small booklet containing about 100
pages with system generated beneficiary credentials affixed on it) and the ePehchan card
is carried by the ESI Beneficiary every time he visits the Diagnostic Centre for availing
diagnostic services.
3. At the time of visit by patient (ESI Beneficiary), the empaneled Diagnostic Centre (eDC)
will check his/her ‘health passbook’ where the investigations are prescribed/written by
hand by the empaneled IMP and shall ascertain bonafide status of the ESIC beneficiary.
The authenticated Health Passbook booklet serves as a tool for identifying the credentials
of the ESI beneficiary and meant for viewing consultation/investigation advice prescribed
by the doctor. The credentials generated from the system contain the demographic details
of a member of the IP-family and Unique Health Identification (UHID) Number. In addition,
it contains mobile no., passport size colored photograph and QR Code. Each IP-Family unit
shall have one common e-Pehchaan card but each member of the family including IP shall
have separate Health Passbook containing Unique Health Id. Normally, the validity of the
Health Passbook is till the last day of the current eligible Benefit Period corresponding to
the previous Contribution Period and is recorded on the Health Passbook. In case of doubt,
additional government issued photo-identity proof may be sought to verify identity and
prevent unethical practices or impersonation.
4. Empaneled Diagnostic Centre will log-in to ESIC Dhanwantri App, feed in the beneficiary’s
credential to ascertain the Check-in number (OPD Number) generated by the IMP Clinic as
also mentioned on the prescription page of the Health Passbook, against which services
are to be rendered.
5. Once the genuineness of ESIC Beneficiary has been ascertained, eDC shall carry out the
investigations as prescribed in the Health Passbook. eDC shall prepare bill/invoice through
its own system and obtain beneficiary’s signature on the cash memo as proof of carrying
out the test and handing over the test reports.
6. Against the Check-in number of a patient in the ‘Dhanwantri Mobile App”, the eDC shall
enter the cash memo (bill) number and date, amount/cost of the test taking account of
the rebate/discount on the price as agreed upon. Thereafter, using mobile camera in the
Dhanwantri App, eDC shall take and upload clear and visible photograph(s) (scan and
upload function) of:
a. cash memo of listed drugs
b. cash memo of unlisted drugs, if any, and
c. IP/family member holding prescription page of Health Pass book and aforesaid cash
memo(s) in hand.
eDC Agreement Document (26/11/19)
6
7. This process shall be irrespective of whether eDC has carried out investigations from the
‘specified List’ (Annexure C) or outside the list (unlisted/CGHS investigations) (as
available at CGHS website https://cghs.gov.in/index1.php?lang=1&level=3&sublinkid=5948&lid=3881). However, the
“Listed” investigations are to be carried out cashless without charging anything to the
beneficiary and original Bill / Cash memo needs to be retained by the eDC for submission
to ESIC later to claim reimbursement.
8. Original Bill / Cash-memo shall be required to be handed over to the ESIC Beneficiary when
the prescribed unlisted investigations are performed against the money received from the
Beneficiary directly against the agreed upon discounted rate on the CGHS rate published
(Annexure F).
9. Irrespective of whether purchased by the beneficiary or availed cashless, the original Bill
/ Cash-memo must contain beneficiaries’ signature certifying receipt and uploaded these
signed bill in the mobile app through scan function.
10. eDC will also keep the photo/ scanned copy of prescription page(s) of the booklet and Bill
and get it signed by patient/ attendant for future claim for reimbursement in case of
cashless services (Approved List of Investigations).
11. At the end of the calendar month in which services rendered, and within 7 days of the next
calendar month the eDC shall submit claim in the prescribed format to Branch office/
DCBO/Regional Office for processing of payment.
12. The eDC shall submit a claim in Hard copy to ESIC (DCBO/BO) for the cashless services
provided to the ESI Beneficiaries during previous month. It is required to be submitted in
prescribed proforma in the 1st week of every subsequent month. The claim should be
supported with summary statement (may also be generated through mobile app),
investigation bill(s) and the test reports along with proof of receipt of the reports by the
patient, on a monthly basis. Branch/DCBO of ESIC will verify claim bills and submit to RO
for cashless online payment or through ECS, deducting any statutory requirements/taxes,
as deemed fit.
13. Upon submission of monthly or quarterly or annual claims, payment of eligible amount
will be made on-line through ECS by Dispensary cum Branch Office (DCBO) in the district/
nearest Branch office/ESIC Office. Hence Bank account and PAN details of eDC are
required to be submitted mandatorily.
SIGNATURE OF FIRST PARTY
SIGNATURE OF SECOND PARTY
DATE:
DATE:
PLACE:
PLACE:
WITNESS 1:
WITNESS 2:
NAME:
NAME:
DATE:
DATE:
PLACE:
PLACE:
WITNESS 3:
WITNESS 4:
NAME:
NAME:
DATE:
DATE:
PLACE:
PLACE:
eDC Agreement Document (26/11/19)
7
Annexure “2”
ECS Mandate form
Second Party Details to receive payment through e-payment
1.
Name of the IMP/Chemist/Diagnostic Centre:
2.
Address of the IMP/Chemist/Diagnostic Centre:
3.
Telephone no of the IMP/Chemist/Diagnostic Centre:
4.
Name of the Account Holder:
5.
Bank Account No.:
6.
Type of the account (S.B., Current or Cash Credit):
7.
Name of the Bank :
8.
Name of the branch :
9.
Bank Address :
10.
Bank Telephone No. :
11.
MICR code number of the bank and branch:
12.
IFSC code number of the Bank & branch
N. B. Please attach a blank cancelled cheque or photocopy of a cheque or front page of your bank
passbook issued by your bank
I, hereby, declare that the particulars given above are correct and complete. If the transaction is
delayed or not effected for reason of incomplete or incorrect information given by me as above,
I would not hold the ESIC responsible.
Dated ___________
(___________________________)
Signature of the Second Party
eDC Agreement Document (26/11/19)
8
Reimbursement Claim Form for empanelled Diagnostic Centre
(mIMP Scheme)
To,
The In charge,
BO/DCBO, ___________________________________,
Employees’ State Insurance Corporation,
_____________________________________________
_____________________________________________
PIN ________________
Sub: Reimbursement of claim for rendering Diagnostic Services for the Month & Year of
______________.
Ref:
Name of Diagnostic Centre: ____________________________________ e-Diagnostic
Centre User ID / Reference No: _______________________
Sir/Madam,
Kindly find attached the claims in prescribed Proforma for providing cashless medical Diagnostic
Test services to ESI beneficiaries under mIMP Scheme for the month & year of ______________.
The duly receipted original bill(s)s/Cash memo(s) and photocopy of relevant prescription page(s)
of the Health Passbook have also been appended for perusal.
Thanking you.
Enclosures:
1. Claim details (as per Prescribed Proforma – Z)
2. Mandate Form (as per Annexure 2)
3. Original Bills / Cash memo of all claims
4. Photocopies of Prescriptions
5. ______________________________
Yours Sincerely,
Date:
Place:
Signature:
Name: __________________________
Mobile No.: _______________________
Email ID: ________________________
eDC Agreement Document (26/11/19)
9
S T A M P
Proforma Z
Claim Submission Form (for empaneled Diagnostic Centre)
for the Month & Year of _________________
Name of Beneficiary,
Age, Gender
Insurance No.
UHID No.
Sl.
No
OPD Check-in No.
Check-
in
Date
Bill
No.
Bill Date
Billed Value
(MRP)
Rebate
(if any)
Claimed
value (Rs)
Remarks
(if any)
Name of Beneficiary,
Age, Gender
Insurance No.
UHID No.
Sl.
No
OPD Check-in No.
Check-
in
Date
Bill
No.
Bill Date
Billed Value
(MRP)
Rebate
(if any)
Claimed
value (Rs)
Remarks
(if any)
Date ___________________
Signature______________________
eDC Agreement Document (26/11/19)
10
“ANNEXURE C”
Listed Diagnostic Tests & Procedures prescribed by ESIC
(Subject to modification from time to time)
Detailed List
ESIC SPECIFIED TEST LIST for modified IMP 15.01.2019
Rate in (Rs) per Unit
Procedure Name / Test name
HAEMOGLOBIN
18
LEUCOCYTE COUNT, DIFFERENTIAL; DLC
31
LEUCOCYTE COUNT, TOTAL; TLC; WBC COUNT, TOTAL
31
ESR (WESTERGREN); ERYTHROCYTE SEDIMENTATION RATE
25
GLUCOSE, FASTING (F)
24
GLUCOSE, POST PRANDIAL (PP, 2 HOURS)
24
GLUCOSE, RANDOM(R)
24
GLUCOSE, FASTING (F) & POST PRANDIAL (PP, 2 HOURS)
47
PROTEIN, SODIUM, CREATININE IN 24-HOUR URINE
50
UREA, BLOOD
54
CREATININE, SERUM
55
BILIRUBIN, TOTAL
80
MALARIA PARASITE/ BLOOD PARASITE IDENTIFICATION
41
SMEAR EXAMINATION, ROUTINE, PERIPHERAL BLOOD
43
PREGNANCY TEST, URINE
65
URINE MICROSCOPIC EXAMINATION, URINE M/E
35
URINE ROUTINE EXAMINATION, URINE R/E
35
URINE EXAMINATION FOR RBCs
35
URINE EXAMINATION, ALBUMIN
70
URINE EXAMINATION, BILIRUBIN
25
URINE EXAMINATION, KETONE BODIES
30
PROTEIN, TOTAL, 24-HOUR URINE
50
BLOOD UREA NITROGEN
54
UROBILINOGEN, QUALITATIVE, EARLY MORNING SAMPLE, URINE
20
ELECTROCARDIOGRAPHY IN 12 LEADS, ECG IN 12 LEADS
50
ELECTROCARDIOGRAPHY WITH LONG II LEAD, ECG WITH LONG II
50
X RAY ABDOMEN, AXR AP VIEW
128
X RAY ABDOMEN, AXR LATERAL VIEW
128
X RAY ABDOMEN, AXR STRAIGHT, KUB VIEW
128
X RAY CHEST, CXR AP VIEW
60
X RAY CHEST, CXR LEFT OBLIQUE VIEW
60
X RAY CHEST, CXR RIGHT OBLIQUE VIEW
60
X RAY CHEST, CXR LATERAL VIEW
60
X RAY CHEST, CXR PA VIEW
60
X RAY SKULL AP VIEW
128
X RAY SKULL AP And LATERAL VIEWS
255
X RAY SKULL LATERAL VIEW
128
X RAY SKULL PA VIEW
128
X RAY SKULL PA And LATERAL VIEWS
255
X RAY CERVICAL SPINE AP AND LATERAL VIEWS
250
X RAY CERVICAL SPINE AP VIEW
125
X RAY CERVICAL SPINE LATERAL VIEW
125
X RAY CERVICAL SPINE LEFT OBLIQUE VIEW
125
X RAY CERVICAL SPINE PA AND LATERAL VIEWS
125
X RAY CERVICAL SPINE PA VIEW
125
X RAY CERVICAL SPINE RIGHT OBLIQUE VIEW
125
X RAY DORSAL SPINE PA VIEW
125
X RAY DORSAL SPINE AP VIEW
125
eDC Agreement Document (26/11/19)
11
X RAY DORSAL SPINE LATERAL VIEW
125
X RAY DORSAL SPINE RIGHT OBLIQUE VIEW
125
X RAY DORSO-LUMBAR SPINE LEFT OBLIQUE VIEW
125
X RAY DORSO-LUMBAR SPINE AP VIEW
125
X RAY DORSO-LUMBAR SPINE LATERAL VIEW
125
X RAY DORSO-LUMBAR SPINE RIGHT OBLIQUE VIEW
125
X RAY LUMBAR SPINE AP AND LATERAL VIEWS
250
X RAY LUMBAR SPINE AP VIEW
125
X RAY LUMBAR SPINE LATERAL VIEW
125
X RAY LUMBAR SPINE LEFT OBLIQUE VIEW
125
X RAY LUMBAR SPINE RIGHT OBLIQUE VIEW
125
X RAY LUMBO-SACRAL SPINE AP VIEW
125
X RAY LUMBO-SACRAL SPINE LATERAL VIEW
125
X RAY LUMBO-SACRAL SPINE LEFT OBLIQUE VIEW
125
X RAY LUMBO-SACRAL SPINE RIGHT OBLIQUE VIEW
125
X RAY SACRO-ILIAC JOINT AP VIEW
110
X RAY SACRO-ILIAC JOINT LATERAL VIEW
110
X RAY SACRO-ILIAC JOINT LEFT OBLIQUE VIEW
110
X RAY SACRO-ILIAC JOINT RIGHT OBLIQUE VIEW
110
X RAY SHOULDER AP And LATARAL VIEWS LEFT
255
X RAY SHOULDER AP And LATARAL VIEWS RIGHT
255
X RAY SHOULDER AP VIEW LEFT
128
X RAY SHOULDER AP VIEW RIGHT
128
X RAY SHOULDER AXILLARY VIEW LEFT
128
X RAY SHOULDER AXILLARY VIEW RIGHT
128
X RAY SHOULDER LATERAL VIEW LEFT
128
X RAY SHOULDER LATERAL VIEW RIGHT
128
X RAY HIP AP VIEW LEFT
128
X RAY HIP AP VIEW RIGHT
128
X RAY HIP LATERAL VIEW LEFT
128
X RAY HIP LATERAL VIEW RIGHT
128
X RAY KNEE AP And LATERAL VIEWS LEFT
255
X RAY KNEE AP And LATERAL VIEWS RIGHT
255
X RAY KNEE AP VIEW LEFT
128
X RAY KNEE AP VIEW RIGHT
128
X RAY KNEE AP VIEW, STANDING LEFT
128
X RAY KNEE AP VIEW, STANDING RIGHT
128
X RAY KNEE LATERAL VIEW LEFT
128
X RAY KNEE LATERAL VIEW RIGHT
128
X RAY ANKLE AP And LATERAL VIEWS LEFT
255
X RAY ANKLE AP And LATERAL VIEWS RIGHT
255
X RAY ANKLE AP VIEW LEFT
128
X RAY ANKLE AP VIEW RIGHT
128
X RAY ANKLE LATERAL VIEW LEFT
128
X RAY ANKLE LATERAL VIEW RIGHT
128
X RAY FOOT AP VIEW LEFT
128
X RAY FOOT AP VIEW RIGHT
128
X RAY FOOT LATERAL VIEW LEFT
128
X RAY FOOT LATERAL VIEW RIGHT
128
X RAY FOOT OBLIQUE VIEW LEFT
128
X RAY FOOT OBLIQUE VIEW RIGHT
128
X RAY HAND AP VIEW LEFT
128
X RAY HAND AP VIEW RIGHT
128
X RAY HAND OBLIQUE VIEW LEFT
128
X RAY HAND OBLIQUE VIEW RIGHT
128
X RAY ELBOW AP And LATERAL VIEWS LEFT
255
eDC Agreement Document (26/11/19)
12
X RAY ELBOW AP And LATERAL VIEWS RIGHT
255
X RAY ELBOW AP VIEW LEFT
128
X RAY ELBOW AP VIEW RIGHT
128
X RAY ELBOW LATERAL VIEW RIGHT
128
X RAY ELBOW LATERAL VIEW LEFT
128
X RAY PELVIS AP VIEW
110
X RAY PATELLA AP VIEW LEFT
128
X RAY PATELLA AP VIEW RIGHT
128
X RAY PATELLA LATERAL VIEW LEFT
128
X RAY PATELLA LATERAL VIEW RIGHT
128
X RAY PNS OM VIEW
110
X RAY RADIUS And ULNA AP VIEW LEFT
128
X RAY RADIUS And ULNA AP VIEW RIGHT
128
X RAY RADIUS And ULNA LATERAL VIEW LEFT
128
X RAY RADIUS And ULNA LATERAL VIEW RIGHT
128
X RAY FEMUR AP VIEW LEFT
128
X RAY FEMUR AP VIEW RIGHT
128
X RAY FEMUR AP, LATERAL VIEWS LEFT
255
X RAY FEMUR AP, LATERAL VIEWS RIGHT
255
X RAY FEMUR LATERAL VIEW LEFT
128
X RAY FEMUR LATERAL VIEW RIGHT
128
X RAY LEG, X RAY TIBIA And FIBULA AP VIEW LEFT
128
X RAY LEG, X RAY TIBIA And FIBULA AP VIEW RIGHT
128
X RAY LEG, X RAY TIBIA And FIBULA AP, LATERAL VIEWS LEFT
255
X RAY LEG, X RAY TIBIA And FIBULA AP, LATERAL VIEWSRIGHT
255
X RAY LEG, X RAY TIBIA And FIBULA LATERAL VIEW LEFT
128
X RAY LEG, X RAY TIBIA And FIBULA LATERAL VIEW RIGHT
128
X RAY ARM AP AND LATERAL VIEWS LEFT
255
X RAY ARM AP AND LATERAL VIEWS RIGHT
255
X RAY ARM AP VIEW LEFT
128
X RAY ARM AP VIEW RIGHT
128
X RAY ARM LATERAL VIEW LEFT
128
X RAY ARM LATERAL VIEW RIGHT
128
X RAY WRIST AP VIEW LEFT
60
X RAY WRIST AP VIEW RIGHT
60
X RAY WRIST LATERAL VIEW LEFT
60
X RAY WRIST LATERAL VIEW RIGHT
60
X RAY WRIST OBLIQUE VIEW LEFT
60
X RAY WRIST OBLIQUE VIEW RIGHT
60
X RAY FINGER LATERAL VIEW LEFT
60
X RAY FINGER LATERAL VIEW RIGHT
60
X RAY FINGER OBLIQUE VIEW LEFT
60
X RAY FINGER OBLIQUE VIEW RIGHT
60
X RAY FINGER, AP VIEW, LEFT
60
X RAY FINGER, AP VIEW, RIGHT
60
X RAY THUMB AP VIEW LEFT
60
X RAY THUMB AP VIEW RIGHT
60
X RAY THUMB LATERAL VIEW LEFT
60
X RAY THUMB LATERAL VIEW RIGHT
60
X RAY THUMB OBLIQUE VIEW LEFT
60
X RAY THUMB OBLIQUE VIEW RIGHT
60
X RAY TOES AP VIEW LEFT
60
X RAY TOES AP VIEW RIGHT
60
X RAY TOES OBLIQUE VIEW LEFT
60
X RAY TOES OBLIQUE VIEW RIGHT
60
Page 1 of 14
AGREEMENT BETWEEN ESIC AND PRIVATE MEDICAL PRACTIONER
[UNDER MODIFIED INSURANCE MEDICAL PRACTITIONER (mIMP)SCHEME]
(To be executed in Rs 100 Non-Judicial Stamp paper)
THIS AGREEMENT (the “Agreement”) is made and entered on the __________ day
of ____________ in the year two thousand and ___________, on the terms and conditions
herein contained:
BY AND BETWEEN
Employees’ State Insurance Corporation (ESIC), represented by Dr. / Mr. / Mrs.
________________________, Age ____, Gender _____, S/O,D/O,W/O_________________,
working as Regional Director/ SRO In-charge, at Employees’ State Insurance Corporation
(ESIC) ___________________(place of office with full address), (hereinafter referred to as
‘ESIC’) which expression shall, unless it be repugnant to the context or meaning thereof, be
deemed to mean and include its successors and assigns) of the ONE PART (FIRST PARTY).
And
Dr. / Mr. / Mrs._____________________, Age ________, Gender _________
S/O,D/O,W/O______________________________ Resident of_______________________
___________________________, (full address), owning/ representing _____________
____________________________________ (Name & address of the Clinic) (hereinafter
referred to as the ‘Registered Insurance Medical Practitioner’ or ‘registered IMP’ under this
Scheme) which expression shall, unless it be repugnant to the context or meaning thereof,
be deemed to mean and include its successors and assigns) of the OTHER PART (SECOND
PARTY).
WHEREAS, the Second Party (IMP) has read the terms and condition of this
Agreement, and has accepted to be engaged as an Insurance Medical Practitioner on the
terms and conditions, and on the remuneration, hereinafter appearing in this agreement and
which he/she has signed in token of acceptance of terms and conditions and the
remuneration mentioned therein.
WHEREAS the registered IMP has agreed to provide Medical services to bonafide and
eligible ESIC Beneficiaries at a rebate of ______ % (________ Percent) on the ‘Rs. 500/-
(Rupees Five Hundred only) per IP-Family per Year ceiling’ and as per stipulated terms and
conditions for a period up to _____, on Contract basis.
WHEREAS, each Party is duly authorized and capable of entering into this Agreement.
NOW, THEREFORE, in consideration of the above recitals, the Parties hereby agree as
follows:
a. TERMS / DURATION /TERMINATION:
i.
The Second Party must not be serving in any organization. A declaration to this
effect must be made and furnished. He must be holding a Degree in Modern
Page 2 of 14
System of Medicine (MBBS - Allopathy) from recognized Medical Colleges of
India. Additional qualifications such as MCh/DM/MS/MD/DNB/PhD/Diploma,
etc., shall be desirable but not mandatory.
ii.
The engagement of Second Party as registered Insurance Medical Practitioner will
be purely contractual during the period of this contract and shall be valid for
initial period of one year, renewable every year on satisfactory performance
services, and extendable for maximum period of 3 years under same terms
and conditions . If either party seeks to terminate this Agreement, the
terminating party must provide 30 days’ notice to the other party or payment @
Rs. 50,000 (Rupees Fifty Thousand only) in lieu of the notice period. However,
the FIRST PARTY reserves the right to terminate the Contract by giving notice of
Seven days, if the SECOND PARTY is in breach of contract. Also, the FIRST
PARTY is entitled to rescind the contract by reason of SECOND PARTY’s
misrepresentation, undue influence or duress or where some unforeseen event
that may prevent the parties to perform the contract.
iii.
The contract period as mentioned in agreement will commence with effect from
the date of signature by both parties and will be counted only from that date on
which after the execution of this agreement by both parties.
b. REMUNERATION:
iv.
Irrespective of the number of consultations / treatments provided to / or count
of episodes of sickness attended, the Second Party shall be entitled to receive
from the First Party a remuneration at a rate not exceeding Rs. ___________ /-
(Rupees __________________________________________ only) per Year per
eligible IP-Family attached to the IMP, as per the terms and conditions of
engagement under this contract. Attachment of IP to an IMP shall be done either
by the Employer or ESIC.
v.
At the end of the calendar month in which services rendered, and within 7 days
of the next calendar month IMP shall submit claim in the prescribed format as
per ‘Annexure X’ to Branch office/ DCBO/Regional Office for processing of
payment.
vi.
Upon submission of monthly claims, payment of eligible amount will be made on-
line through ECS by BO/ Dispensary cum Branch Office (DCBO) in the district/
nearest Branch office/ESIC Office. Hence Bank account and PAN details of IMP
are required to be submitted mandatorily (Annexure 2).
vii.
The Second Party shall get remuneration only for such of the above period when
he/she actually performed his/her assigned work. No additional amount shall be
admissible to him/her irrespective of the work actually rendered by him/her.
Aforesaid payments would be subject to applicable TDS as per Income Tax Act
and other statutory taxes.
viii.
The Second Party would receive monthly remuneration from the First Party based
on average number of attached eligible IPs with the Second Party as shown in
‘Dhanwantri’ app/ as per system derived information. Calculation of monthly
average number of attached eligible IPs would be equal to half of the sum total
of eligible IPs attached to the IMP on 1st day of that month and that of the
subsequent month. For example, to arrive at the eligible attached IP Count for
the month of February, the average of count on 1st day of February and that of
March is to be accounted. The count on 1st day of a month shall show information
Page 3 of 14
as on 24.00 hours on the last day of the previous month. However, in case, a
contract starts or ends on a date other than 1st or last date of the month, the
count on that date shall be taken into account as one of the parameters for
calculating the average. The final payable amount per month shall be calculated
as “the average number of eligible ‘attached IP-Family units’ multiplied by (‘X’ /
12), where ‘X’ being the remuneration as per point b(i) above”, subject to pro-
rata deductions of number of days of unavailability of services [to be multiplied
by {(No. of days in the month – No. of days of absence of services) / No. of days
in the month} and taxes as applicable. The final calculation to arrive at payable
amount per month is:
{(A) * (X/12) * (B) – (Y)}
Where
A = Average No of attached eligible IP
X = The agreed upon remuneration per IP Family per Year
B = {(No. of days in the month – No. of days of absence of services) /
No. of days in the month}
Y = Taxes, if any
vi.
At no point of time the Second Party would be entitled for remuneration in excess
of 2000 eligible IP family-units as attached to the Second Party as defined by
System/Application.
vii.
Non-attached IP or his family member may be treated as a private patient by the
Second Party for which the First party will neither object nor be responsible for
payment or any other purpose. However, this should not come in way of quality
of service being rendered to the attached IPs or their families.
c. THE SCOPE OF SERVICES:
The Second Party shall provide services to the Beneficiaries and abide by instructions
as specified in “Annexure A” (the “Services”). Any modification in the instructions
shall be conveyed on the registered e-mail address of the registered IMP.
d. RESPONSIBILITY OF THE SECOND PARTY:
The First Party (ESIC), in all good faith shall pay remuneration, as defined and as
agreed, to the Second Party (IMP), within 15 days of receipt of complete and correct
remuneration Claim from the Second Party.
e. LISTED MEDICINES AND INVESTIGATIONS:
Normally, the Second Party (IMP) is expected to prescribe from the ESIC specified
Medicine List (“Annexure B”) and Investigations List (“Annexure C”). However, in
exceptional circumstances and clinically demanding cases the IMP may prescribe
judiciously outside the “Lists” with precautions as specified in the “Scope of Services”.
f. INDEPENDENT CONTRACTOR STATUS:
The Second Party shall be serving as an independent contractor in providing the
Services. Under this Agreements, the Second Party is neither an employee nor a
partner of ESIC.
Page 4 of 14
g. PROPRIETARY INFORMATION.
All work performed under this Agreement, including without limitation to all notes,
reports, medical records, documentation, drawings, computer programs, inventions,
creations, works, devices, models, work-in-progress and deliverables will be the sole
property of ESIC, and the FIRST PARTY hereby assigns to the SECOND PARTY rights to
perform and discharge all medical and clinical duties towards the patients (ESIC
Beneficiaries).
h. GOVERNING LAW.
The laws of the State of India govern all matters arising out of or relating to this
Agreement and the transactions it contemplates, including, without limitation, its
interpretation, construction, validity, performance, and enforcement.
SIGNATURE OF FIRST PARTY
SIGNATURE OF SECOND PARTY
DATE:
DATE:
PLACE:
PLACE:
WITNESS 1:
WITNESS 2:
NAME : NAME:
DATE :
DATE :
PLACE :
PLACE :
WITNESS 3:
WITNESS 4:
NAME : NAME:
DATE :
DATE :
PLACE :
PLACE :
Page 5 of 14
“ANNEXURE A”
THE SCOPE OF SERVICES & OTHER DUTIES OF THE SECOND PARTY (IMP)
A. SCOPE OF SERVICES:
The Second Party (IMP) shall provide the services (the “Services”) as follows:
1) The Second Party (IMP) shall provide Out Patient Medical treatment & services in his
private clinic / premises without charging any fees from the eligible and bonafide
Insured Persons of ESIC and their dependent family members’ (the “Beneficiaries”) as
attached/tagged to him (by the employer/ESIC or otherwise) in the Employers portal
of Insurance module of Panchdeep. The IMP shall also provide First Aid and Basic Life
Support Services to the Beneficiaries who shall need treatment in case of an accident
or any other emergency as per law of the land.
2) The IMP shall be provided with user credentials (User ID & Password, etc.) through
valid e-mail ID and/or working Mobile number by ESIC to access “Dhanwantri Mobile
App” and work for ESIC (refer and report to ESIC as per work assigned in this
agreement). IMP shall download ESIC “Dhanwantri Mobile App” in his/ her
Smartphone with Android OS from Google Play store & log-in into it. The SIM Card of
the mobile number registered with ESIC must be in the same smartphone device
where the Mobile App has been downloaded to authenticate user through OTP.
3) Beneficiary shall always carry the ‘Health Passbook’ (A small booklet of A5 size approx.
containing about 100 pages with system generated beneficiary credentials affixed on
it) every time he visits the IMP/ dispensary. IMP shall use the Health Passbook as a
tool for identifying the credentials of the ESI beneficiary and record clinical findings &
consultation advice.
4) The system generated credentials on the Health Passbook displays the demographic
details of a member of the IP-family and Unique Health Identification (UHID) Number.
In addition, it contains mobile no., passport size colored photograph and QR Code.
Normally, the validity of the Health Passbook is printed on the Health Passbook and
is till the last day of the current eligible Benefit Period corresponding to the previous
Contribution Period.
5) The IMP may also verify the authenticity of the Beneficiary from the e-Pehchaan
Card (I Card of ESIC) issued to the Insured Person (IP)/ Insured Women (IW). Each
IPFamily unit shall have one common e-Pehchaan card but each member of the family
including IP shall have separate Health Passbook containing UHID Number.
6) In case of doubt, additional government issued photo-identity proof may be sought
to verify identity and prevent unethical practices or impersonation.
7) At the time of visit of tagged and eligible IP/beneficiary to the IMP, the IMP will enter
in the App, the Insurance/UHID Number of the beneficiary or scan the QR code
available on the Credentials page of the “Health Pass book” to check eligibility using
“Dhanwantri App”.
Page 6 of 14
8) The IMP shall proceed further and capture certain clinical information including
provisional ailments from International classification of disease (ICD-10) in drop box
as given in the App, based on complaints and clinical examination of patient.
9) IMP will prescribe medicines in the beneficiary’s Health passbook, manually, as per
prescribed list of drugs and investigations as published by ESIC from time to time.
When drugs or investigations are prescribed from the specified list, the beneficiary
gets the services cashless from the empanelled Chemist (eC) or Diagnostic centre
(eDC).
10) The drugs are to be prescribed in standard Generic Name, other than in exceptional
or unavoidable circumstances. Prescribing in brand names is highly discouraged for
administrative and clinical reasons.
11) All drug and test names are to be prescribed in the Health Passbook in clear legible
writing, preferably in capital letters. The consequences of ineligible prescription
writing shall be that of the IMP.
12) Thereafter, in the Dhanwantri App, IMP will input count (number) of listed and
unlisted drugs or diagnostic investigations as prescribed in the health pass book of IP/
family member.
13) The IMP shall also capture information in the Dhanwantri app about a suspected
Occupational Disease (OD) (as per the definition of Occupational Disease) and
Employment Injury (EI) (As per definition of Injury sustained during in-job
performance), over and above documenting the same in the health passbook. A prior
knowledge on OD and EI as per ESI Context is not only essential but also has legal and
administrative consequences.
SICKNESS CERTIFICATE
14) If certificate of leave [‘Sickness Certificate’ as per definition of ESIC] needs to be
prescribed in the prescribed certificate booklet manually, IMP must also input the
Sickness Certificate number (as mentioned on the leaf of the certificate book) along
with recommended number of days of rest in the Dhanwantri App. IMP must be
judicious while recommending leave. In a single spell, leave recommendation must
not exceed 7 days in one event of sickness, and it should not exceed 30 days in a year).
15) Through Mobile App the IMP shall also capture information about “Maternity
Certificate” and other stipulated Certificates that has been prescribed in the specified
Certificate Booklet provided/issued by DCBO/ RD Office.
16) Sickness/Maternity certificate, unlike ordinary medical certificate is a highly regulated
document based on defined logic and nomenclature. Issuance of Sickness /Maternity
Certificate needs knowledge about ESI Scheme rules and must be learnt from the ESIC
Office. Misuse or wrong use shall bring in complications and legal /administrative
consequences. Issuance of regulated Sickness / Maternity Certificate is permissible to
Insured Person (including Insured Women) only, as the case may be, and not to the
Family Members. However, normal medical certificate may be issued on the
letterhead of the IMP to family members, which has no bearing on cash benefits and
liability on ESIC. Issuance of Sickness / Maternity certificate shall be subject to remote
Page 7 of 14
verification by Medical Referee/ DCBO doctor, or other officer of ESIC/ESIS. The
resulting Cash benefit, if any shall be directly deposited in the bank account of the IP
and shall be regulated. Issuance of lax/bogus certification by IMP is a criminal offence
and all certifications shall be under constant scrutiny.
17) During the contract period the used Sickness/Maternity Certificate Booklet with
carbon copies of certificates issued must be returned by IMP along with the filled in
form (‘Annexure 3’) to the ESIC office which has issued the booklet. Similarly, at the
end of the contract of the IMP, the Certificate Booklet with unused leaflets must be
returned to the ESIC Office along with the prescribed the form (Annexure 3). It must
be understood that the certificate booklets are important document that needs to
securely kept and appropriately maintained to prevent any legal or financial liabilities
on the IMP.
REFERRAL
18) In case the illness/condition of the patient is such that it requires treatment that is
not within the IMP’s obligations/capacity or a referral is required to higher center
(except in emergency) for secondary or tertiary medical care, he may inform the
patient and refer him to the nearest ESIC/ESIS Hospital/ Dispensary cum Branch Office
(DCBO) of the district for further necessary action. The same has to be recorded in
the Health Passbook and also in the mobile App in the remarks field.
19) The IMP may refer beneficiaries who require consultation with Medical Referee (MR).
He shall answer in writing, if needed, within a reasonable period as specified by the
MR, any query raised by the MR in regard to any prescription or certificate issued by
him or any statement made in any report furnished by him under these terms of
service. The same has to be recorded in the Health Passbook and also in the mobile
App in the remarks field.
OTHER PROCESSES
20) Once manual documentation in the health passbook is complete, IMP shall capture
(scan & upload function) clear and visible photograph(s) of
a. prescription page of the health pass book and
b. also the beneficiary holding prescription page in his/her hand
in the ‘Dhanwantri App’, and click Complete to end the process. The check-in number
shall be generated at this stage in the App which needs to be recorded in the Health
Passbook. This number shall also get reflected for further action by the empaneled
Chemist / Diagnostic Centre.
21) In all cases, the top of the prescription page of the Health pass book should be
stamped with details of patient’s name, age, gender, date, check in number, sickness
certificate number and the number of days of rests (if any) duly filled in by IMP. A
Page 8 of 14
sample
design
of
the
stamp
is
produced
below:
Besides clinical finding and recommended drugs/ diagnostic procedures the
prescription should end with sign and named stamp of the IMP. A sample design of
the stamp is represented below:
22) IMP should take note of the fact that until realization of reimbursement by ESIC,
prescribing unlisted drugs/ diagnostic procedures would cause additional financial
burden on IP and in extreme cases IP may even prefer attachment with some other
IMP or file complaint with employer/ ESIC.
23) The Regional Office/DCBO, at the time of empanelment of an empaneled Chemist
(eC) / Diagnostic Centre (eDC), shall be tagging an IMP Clinic so as to help beneficiaries
avail services from these eC/eDC. More than one eC and/or eDC can be attached to
an IMP Clinic or vice versa to bring in ease of service delivery and competition.
24) Along with IMP’s prescription in Health Pass Book, the IP/Beneficiary shall visit the
designated eC / eDC respectively for availing services. Similar to that of IMP Clinic,
both eC and eDC will also have to download the ESIC “Dhanwantri” app to log-in with
the ESIC issued user credentials.
25) If unlisted drugs or investigation is required to be prescribed by the IMP in special
circumstances, the beneficiary shall have either of the two options: To pay from
pocket and avail the drugs / services from the eC/eDC and later claim reimbursement
from ESIC/DCBO producing copies of bills, proof of receipt and prescription on the
Health Passbook; OR, avail these from DCBO, free of cost. This implies that the eC/eDC
shall charge the cost from the patient as per the agreed upon rate (Discount on
Page 9 of 14
MRP/CGHS Rate) upfront when purchased by the beneficiary and issue the Bill and
capture information in the relevant fields of Mobile App.
26) The IMP shall report death of an insured person or a family member and forward the
Medial Record to the concerned Branch Manager, ESIC Branch Office within 7 days.
A copy of the same should also be sent to the RD, ESIC/Director, ESIS Medical Services.
B. GENERAL DUTIES AND RESPONSIBILITIES:
i.
The Second Party (IMP) will engage himself/herself in the treatment of IPs and their
family members efficiently and diligently. He/she will devote his/her time during the
assigned clinic hours to his/her work and duties.
ii.
The IMP as a medical doctor shall have an obligation of means toward his patients,
not an obligation of result. This means that the IMP shall take appropriate steps
available to make the right diagnosis, provide treatment and follow-up on the
patients' progress.
iii.
The IMP must treat their patients attentively and conscientiously. He / She shall
prescribe the right medication, tell patients about the advantages, disadvantages,
risks and alternatives regarding a proposed treatment or operation, and provide
adequate follow-up to the patient within a reasonable amount of time. He / She must
give the patients all the information such as diagnosis, nature, goal and seriousness
of the treatment, risks of the treatment, other treatment options so as to help them
make free and informed decisions.
iv.
The IMP shall maintain the duty of professional secrecy and respect his/her patients'
confidentiality. This duty covers both the information which patients tell their doctor
and any facts doctor discovers about the patients as part of the doctor-patient
relationship. It must be understood that the Professional secrecy belongs to the
patient, not the doctor. Doctor shall reveal what the patients tell them, unless the
patients waive the confidentiality of the information or if the law allows it (i.e. Public
Health agencies).
v.
The IMP shall maintain trust. He shall never abuse patients' trust in him/her or the
public's trust in the profession. He should be honest and open and act with integrity.
He/She shall never discriminate unfairly against patients or colleagues.
vi.
The IMP will abide by the rules pertaining to the Professional Conduct, Etiquette and
Ethics as notified under Indian Medical Council (Professional conduct, Etiquette and
Ethics) Regulations, 2002, and amendments made thereto from time to time.
Page 10 of 14
vii.
The IMP shall be governed by the Professional liability (PL) clause as defined in the
Law from time to time for the professional failure resulting in damages to the patients
who are required to be compensated monetarily.
SIGNATURE OF FIRST PARTY
SIGNATURE OF SECOND PARTY
DATE:
DATE:
PLACE:
PLACE:
WITNESS 1:
WITNESS 2:
NAME:
NAME:
DATE:
DATE:
PLACE:
PLACE:
WITNESS 3:
WITNESS 4:
NAME:
NAME:
DATE:
DATE:
PLACE:
PLACE:
Page 11 of 14
Annexure “2”
ECS Mandate form
Second Party Details to receive payment through e-payment
1.
Name of the IMP/Chemist/Diagnostic Centre:
2.
Address of the IMP/Chemist/Diagnostic Centre:
3.
Telephone no of the IMP/Chemist/Diagnostic Centre:
4.
Name of the Account Holder:
5.
Bank Account No.:
6.
Type of the account (S.B., Current or Cash Credit):
7.
Name of the Bank :
8.
Name of the branch :
9.
Bank Address :
10.
Bank Telephone No. :
11.
MICR code number of the bank and branch:
12.
IFSC code number of the Bank & branch
N. B. Please attach a blank cancelled cheque or photocopy of a cheque or front page of your bank
passbook issued by your bank
I, hereby, declare that the particulars given above are correct and complete. If the transaction
is delayed or not effected for reason of incomplete or incorrect information given by me as
above, I would not hold the ESIC responsible.
Dated ___________
(___________________________)
Signature of the Second Party
Page 12 of 14
Remuneration Claim Form for empanelled IMP (mIMP Scheme)
To,
The In charge,
BO/DCBO, ___________________________________,
Employees’ State Insurance Corporation,
_____________________________________________
_____________________________________________
PIN ________________
Sub: Claim for Remuneration for providing Medical Services for the Month & Year of
________.
Ref:
Name of IMP Clinic: _____________________________
IMP User ID / Reference No: ______________________
Sir/Madam,
I am enclosing the claims in prescribed proforma for providing cashless services of Insurance
Medical Practitioner to the eligible ESI beneficiaries under mIMP Scheme for the
month/quarter of ___________ subject to applicable TDS/deductions, kindly remit the net
payable amount to my bank account.
Thanking you.
Enclosures:
1.
Claim details (as per Prescribed Proforma – X)
2.
Mandate Form (as per Annexure 2)
3.
______________________________
Yours Sincerely,
Date:
Place:
Signature:
Name: ___________________________
MCI Registration No.________________
Mobile No.: ______________________
Email ID: ________________________
Page 13 of 14
Proforma – X
Claim Submission Form (for IMP) for the Month & Year of _________________
No of days of absence from Service: _________________________
Date of Joining as IMP as per Contract:_______________________
End Date of Validity of Contract: ____________________________
A
B
C
D
E
H
Count of eligible IP
Family Units tagged
on the 1st day of the
month of Claim / 1st
day of appointment
Count of eligible IP
Family Units tagged
on the 1st day of the
immediate
subsequent month/
Last day of Contract
Average of
Count
[(A + B) / 2]
Days of
Absence from
service /
Non-
availability of
Service
Claimed
Amount (Rs.)
[As per
formula]**
Remarks
**Claimed Amount is to be calculated as per following formula =
Rs. 500 (100 – Rate of Discount) No of Days in the - No of days of absence# Average IP Count (C)
------------ x --------------------------------- x ------------------------------------------------------- x ---------------------------
12 100
No of days in the month
# Note: No of days absence of services of IMP = Days of leave during the month + days prior to joining date (or days after the contract
validity date during the month)
Date ____________________ Signature________________
S T A M P
Page 14 of 14
Annexure “2”
Return / Request Form: Sickness Certificate Booklet
To,
The In charge,
BO/DCBO/RO, ___________________________________,
Employees’ State Insurance Corporation,
_____________________________________________
PIN ________________
Sub: Request for new / Return of (partially-used/fully-used/unused) Sickness Certificate
Booklet
Ref:
Name of IMP Clinic: _____________________________
IMP User ID / Reference No: ______________________
Sir/Madam,
In case of Return
I am returning herewith the partially-used / fully-used / unused (Strikeout whichever is not
applicable) Sickness Certificate booklet bearing leaflet number from __________ to
____________ on termination of my contract / against request of issuance of new certificate
booklet (Strikeout whichever is not applicable).
Date of Issuance/Receipt of new Certificate Booklet:
____________________
Date of Return of used/unused/partially used Booklet:
____________________
No./Count of leaflets used:
____________________
Reason for returning:
____________________
OR
In case of new issuance request
I may kindly be issued a Sickness Certificate Booklet to discharge my Clinical and
administrative responsibilities.
Thanking you.
Enclosure(s): Used/ unused Certificate Booklet
Yours Sincerely,
Date:
Place:
Signature:
Name: ___________________________
MCI Registration No.________________
Mobile No.: ______________________
Email ID: ________________________
