SYSTEM REQUIREMENTS CHECKLIST

S. No

System Requirements

Availability

Hardware specifications:
1

Processor: Intel Pentium IV or Higher; Monitor:

Min 14" Color Monitor
RAM: 512 MB; Hard Disk: 40 GB

Operating system: Windows 2000/XP

professional with service pack. Browser: Internet
Explorer 6.0 or higher.

Dedicated and uninterrupted high speed internet

facility

Scanner with ADF facility available and attached

to the Computer where application will be used.

Printer available to print from the computer

where application will be used.

Hospital Seal & Signature

Health SuperHiway Pvt. Ltd., Life Sciences Building, Apollo Health City Campus, Hyderabad- 500096 (AP)
Phone: +91- 040- 66658888 Fax: +91-040- 66419908 E-mail: support@healthhiway.com

ENTITY REGISTRATION FORM

Claims XchangeTM Application
Name of the Hospital

: ________________________________________________________________

Hospital Registration No: ________________________________________________________________

Address

: ________________________________________________________________
_______________________________Pin_________________________

No of Avg Claims per month

: _____________________

Bed Strength

: _____________________

Hospital Representative : _________________________________________________________________

Designation

: _________________________________________________________________

E-mail

: _________________________________________________________________

Phone

: ______________________________Fax: ________________________________

Mobile

: _________________________________________________________________

Contact Person for Billing: ________________________________________________________________

Designation

: _________________________________________________________________

E-mail

: _________________________________________________________________

Phone

: ______________________________Fax:_______________________________

Mobile

: ________________________________________________________________

Signature: ____________________________

Date: _____________________

Hospital Seal

_________________________________________ (For Office use only) ________________________________

Application No: __________________________
Customer ID: ____________________________

Approving Authority

Health SuperHiway Pvt. Ltd., Life Sciences Building, Apollo Health City Campus, Hyderabad- 500096 (AP)
Phone: +91- 040- 66658888 Fax: +91-040- 66419908 E-mail: support@healthhiway.com

USER DETAILS

User 1

: ________________________________

User 2

: _____________________________

Designation : ________________________________

Designation

: _____________________________

E-mail

: ________________________________

E-mail

: _____________________________

Phone

: ________________________________

Phone

: _____________________________

Mobile

: ________________________________

Mobile

: _____________________________

User 3

: ________________________________

User 4

: _____________________________

Designation : ________________________________

Designation

: _____________________________

E-mail

: ________________________________

E-mail

: _____________________________

Phone

: ________________________________

Phone

: _____________________________

Mobile

: ________________________________

Mobile

: _____________________________

User 5

: ________________________________

Designation : ________________________________
E-mail

: ________________________________

Phone

: ________________________________

Mobile

: ________________________________

Health SuperHiway Pvt. Ltd., Life Sciences Building, Apollo Health City Campus, Hyderabad- 500096 (AP)
Phone: +91- 040- 66658888 Fax: +91-040- 66419908 E-mail: support@healthhiway.com