Memorandum of Understanding

This memorandum of understand is entered into on at

New Delhi between East West Assist TPA Pvt. Ltd, a third party administrator having it’s
office.

East West Assist TPA Pvt. Ltd.

Plot No-172, J P House, Lane-2
Westend Marg, Saidulajab,
Next to Saket Metro Station, New Delhi - 110030
Mob.9711779711, 011-47222666: Fax No. 29554130, 29553033 / 47222640-426
E-fax 022-66466-9006
Email: network@eastwestassist.com
Website: www.eastwestassist.com

Represented by its C.E.O /M.D /C.O.O / DIRERCTOR’s

And

M/s Hospital, having its office

At herein after referred to as

The hospital /nursing home /clinic

Whereas the above two parties have decided to enter into an agreement to provide
medical services to the health insurance sector and other corporations whereas the
parties have decided to set out in writing the terms and procedures based on which the
agreementbecomes operational for a validity of 3 years.

Now this memorandum of understanding shall witnessed as under

Purpose
To enroll the hospital as a participating healthcare provider to the East West
Assist(EWA) group of service provider.

I EWA will provide the following services by virtue of this agreement

1. To provide insurance companies and employees of corporations information

andaccess to quality health care.
2. To base with health insurance sector.
3. To offer cashless services to clients through the provider network.
4. To provide a twenty four hour alarm center
5. Being listed as a preferred care provider on the list of EWA
6. EWA will settle all approved, reasonable bills within 30 days of receipt of bills and
supporting documents as details in the attached annexure

II The hospital/nursing home/clinic shall provide

The _______________________________ Hospital/nursing home/clinic by virtue of

being a preferred provider for EWA clients, theHospital will provide the following services.

1. All clients will be received and treated on a priority basis at all times.
2. Soon after admission or arrival of the patient and no later than 24 hours, the EWA
alarm center will be notified of the patients admission so that authorization of services
may be processed and communicated by EWA to the hospital at the earliest.

3. The hospital will provide cashless services to EWA clients on obtaining authorization
4. The procedure for obtaining authorization is set out on a separate document that
isbeing provided with this Memorandum of understanding.

5. For payment after authorization by EWA; the hospital must supply all document
aslisted in Annexure B.
 6. All bills must be submitted promptly by the hospital but no later than seven days of
discharge of the patient for prompt reimbursement.

7. No liability whatsoever shall develop on EWA in the event that facts have been
concealed form EWA regarding the nature of the patients past or present history or on
account of late submission or compliance of instructions as laid out and hence rejected
by the insurance company.

8. The hospital shall always inform EWA in writing whenever their tariff is revised,
some new services added or services/ facilities curtailed.

III

1. The role of EWA is to ensure that the best possible services to their clients at the
most reasonable and competitive costs.

2. It is made explicitly clear that in so far that any services that maybe provided by
networked hospital provider to its clients in so far as it leads to any negligence or
deficiency in service on part of the hospital wherein the client or his or her family
members has taken treatment, EWA shall not in any way be liable or responsible for
anysuch negligence, deficiency or damages.

IV Laws and Jurisdiction

For all disputes that may arise by the virtue of this agreement, the laws of India
shallapply and the jurisdiction shall be the courts at New Delhi, India.

V Modification

This agreement can be modified from time to time by mutual consent of both parties

Signed for EWA Signed for Hospital

Signature Signature
Name Name
Title/Designation Title/Designation
Name of Hospital/Nursing
home/clinic
Date Date
 Annexure A

The hospital must provide the following information for the purpose of
efficient functioning of the relationship with EWA and rapid processing of
the claim.

1. A recent brochure of the hospital with current tariff list of services and
procedures that are carried out at the hospital/nursing home/clinic.

2. List of various specialties available in your hospital

3. Name and phone number of persons who may be contacted on an

emergency basis on holidays and at night, the contact details of the
physician in charge of the patient should be given.

4. Any suggestions you may have for smooth functioning of this relationship.

5. Phone number, mobile number, all contact details of the owner, medical
director or person with authority in charge of handing insurance formalities
at the hospital Email address to be included if present.
6. Bank details of the hospital to be provided for a rapid wire transfer for
payment.

7. If there is any change in address, contact phone number, fax, email,

address, of the hospital, personal email, accounts section or contact
person of the hospital, it should be intimated in writing by fax, post or
email to EWA at the earliest.
 Annexure B

When the hospital submits bills, kindly ensure that all the following
documents are attached:

1. Hospital bill in original with bill breakups; to be signed by signed by the

patient before discharge from the hospital whenever possible,

2. Original reports of all investigations such as, ECG, X-ray, Ultrasound, CT

scan etc., even if the test has been repeated, all repeat reports to be
attached , All the reports should be signed by the treating physician or the
medical superintendent.

3. Photocopy of the insurance policy of patient and their identification card

(both sides of the card).

4. In case investigations are done at a place other than the hospital/nursing

home/clinic, kindly provides original bills along with the original reports
5. Discharge Summary in original.

6. Pharmacy bills and breakups of the bill.

7. Doctor prescriptions in original.

8. Operation theater & OT consumables breakups

9. Claim form with signatures of patient.

This list may be modified from time to time for efficient processing of claims and
shall be intimated to you in writing.
 Annexure C

When requesting authorization from the alarm center of EWA, kindly provide
the following Information by phone call which should be promptly followed by
fax or email.

1. Full name of patient

2. Age
3. Sex
4. Residential address
5. Name of insurance company/ corporation
6. Policy number
7. Identification card number
8. Dates of validity from to
9. Name of Hospital
10. Name of treating doctor
11. Contact phone numbers of treating physician/surgeon
12. Patients location in the hospital/ bed number/ room number
13. With extension number of bedside telephone
14. Date and time of admission
15. Working diagnosis
16. Medication given and investigations done at the time of informing EWA
17. Approximate daily cost
18. Likely number of days the patient may be hospitalized
19. If any family members or companion is with the patient.
 East West Assist TPA Pvt. Ltd. Plot No-172, J P House,
Lane-2 , Westend Marg, Saidulajab,
Next to Saket Metro Station.
New Delhi - 110030
Mob.9711779711,011-47222666: Fax No.29554130, 29553033, 47222640-426
E-fax 022-66466-9006
Email: network@eastwestassist.com
Website:www.eastwestassist.com

DETAILS OF PRIVATE NURSING HOME / HOSPITAL

Name of hospital

Address

Phone numbers

Fax

Email

Website
Total number of beds

Double room (approx.

charge) Single room

(approx. charge)
Name of Medical Director

Contact number / Mobile :

Name of medical superintendent

Contact number / Mobile :

In case of emergency / notification
calls from our organization to your
hospital, the Person to contact :
Name and contact number / Mobile :
Name of Financial Officer /
Accounts officer
Contact number / Mobile :

Hospital Services

Are the following available? YES NO

Imaging
X-ray
Doppler
Ultra sound
CT scan
MRI
 Barium studies

Laboratory
Hematology
Biochemistry
Serology
If in-house ABG (arterial blood gas examination)
not available.
Is it possible to send the sample elsewhere?
Histopathology
HIV 1
HIV 2
Cardiology
Electrocardiograph
Echo
Defibrillator
Cardiac monitor
Pacing – Temporary
-Permanent
TMT
Holter
Respiratory
Spirometry
Nebulizer
Ventilator
Oximetry
 BIPAP
Pharmacy
24 hours and only for inpatients?
Available to general public?
Blood bank – In house?
In house – is blood checked for - HIV 1
HIV 2
Hepatitis B
Hepatitis C
If not in hospital, which blood bank’s is used
Please provide name and phone number of the
bank.
Surgery
Operation theater ( number minor/major)
C arm available
CTVS (cardio thoracic vascular surgery)
Cardiac Bypass
General surgery
Neurosurgery
Please add other if available

Emergency
Ambulance- size and type of vehicle available
Emergency room
24 hour resident in the hospital
Specialists on call

Or present 24 hour in the hospital

Nephrology
Peritoneal Dialysis
Haemodialysis
Renal transplant

Gastroenterology
Endoscopy
Colonoscopy
ERCP

Neurology
EEG (electro encephalogram)
Sleep lab
EMG / NCV (electro myelogram / nerve
conduction studies)

Orthopedics
Acute Trauma can be rapidly operated
Joint replacement

Special care units

Intensive care unit –ICU
Intensive Coronary Care unit – ICCU
Pediatric intensive care unit – PICU

Maternity / OBGYN
Delivery / labor room
Gyne operations (hysterectomy etc.)

Pediatrics Yes No
Ventilator
Nursery
Incubator
Neonatologist

Other departments
Please add other specialties, services, facilities
available in Your institution
Dentistry
Dietitian
Dermatology
Endocrinology
Hematology
Psychiatry
Physiotherapy
Oncology
Other information
Food for patients available
Private duty nurses available
Oxygen
MOU signing date Validity till

Form filled by:

Signature:
Designation:
Please attach hospital/nursing home/clinic brochure, charge schedules of
laboratory, Investigation, Room charges etc. Please add additional sheets if
required.

THANK YOU FOR TAKING THE TIME TO FILL THIS FORM

No membership fee required