(To be submitted in the Institute Letter Head in Triplicate)

Sub: Empanelment for Clinical laboratory Services to Railway patient referred from ICF Hospital, Chennai – 38 for a period of two years from the commencement of services.

Ref: Railway Board’s letter No.2011/H/6-4/Policy Dated 03-02-2015 ****

Terms and Conditions

1. The Laboratory Should possess valid NABL Accrediation certificate and shall

enclose copy of the valid certificate along with the scope of Accrediation. In case the laboratory is already accrediated by the NABL and the validity has expired, the Laboratory shall enclose a copy of renewal application submitted and direction by NABL in this regard., for the inspection date if any, The laboratory shall be empanelled only for those investigations for which scope of Accrediation exists. However, the Institution shall posses a valid NABL Accrediation certificate on the date of issual of letter of Acceptance. Any offer EOIfrom Laboratories without the above documents will be summarily rejected

2. The Laboratory shall give an undertaking to allow the team of Doctors from ICF Hospital for inspection of their laboratory facilities after opening of the offers.

3. The offer shall hold good for a period of two years from the commencement of services or till ICF makes its own arrangements for this facility whichever is earlier.

4. Emergecny requisition during odd hours and holidays will be acted. 5. The laboratory shall make arrangements to collect samples at ICF Hospital and

also deliver the reports in duplicate to the designated person(s) in the Hospital within 24 hours for regular investigations and within reasonable period for specialized investigations/procedure.

6. We have enclosed a detailed list of investigations for which empanelement is sought for Institution are advised to quoted only for those investigations/Procedure in which have they scope for NABL Accrediation as mentioned in Para I.

7. The Institution shall adhere to CGHS 2014/Chennai/ AIIMS rates for the investigations/Procedure as mentioned in para 6. In case of variation of rates , the same may be mentioned against each investigation/procedure. However, the Institutions adhering to the CGHS- 2014 Chennai rates will be preferred..

8. If no CGHS/AIIMS rates are available for the investigations/Procedures mentioned the institution are advised to adhere to AIIMS rates wherever available. A copy of rate list of AIIMS is enclosed for your guidance. Howevere the Institution are advised to visit CGHS website www.mohfw.nic.in/cghsnew/index.asp and AIMMS website www.aiims.edu/aiims/hosp.serv/revised rate-list.htm for authentication. In case where no CGHS/AIMS rates are available for a particular item, the Institution are

advised to quoate their lowest rate for the same, which should not be more than the rates being charged fro the general public.

9. Only those ICF patients authorized by te Chief Medical Officer/ICF Hospital or his Authorised signatory are eligible for the facility. ICF patients approaching your Institution directly for investigations/procedure are not eligible for this facility.

10. Pre receipted bills (in triplicate) will be submitted on the 5th of the previous each month covering the investigations done from 1st to 31st of the previous month . bills will be signed only by the Authorized Signatory/signatories nominated by the institution.

11. Details such as, Name, Age, Sex, Emp.No, Designation of the employee should be entered in the bill.

12. Along with each bill one copy of the report shall be submitted. 13. Payment towards cost of investigations are liable for tax deduction at source in

terms of Income Tax act. 14. No increase in the tariff shall be entertained during the agreement period.

Dated: Signature: (Authorized Signatory) Name:

(In Capital Letter) Designation

(Stamp of the Institution)

LIST OF ITEMS COVERED UNDER CGHS

S.No. Sl.No. as per CGHS LABORATORY MEDICINE / CLINICAL PATHOLOGY

1 1383

Urine routine- pH, Specific gravity, sugar, protein and microscopy

2 1384 Urine-Microalbumin

3 1385 Stool routine

4 1386 Stool occult blood

5 1387 Post coital smear examination

6 1388 Semen analysis

LABORATORY MEDICINE / HAEMATOLOGY

7 1389 Haemoglobin (Hb)

8 1390 Total Leucocytic Count (TLC)

9 1391 Differential Leucocytic Count (DLC)

10 1392 E.S.R.

11 1393 Total Red Cell count with MCV,MCH,MCHC,DRW

12 1394

Complete Haemogram/CBC, Hb,RBC count and indices, TLC, DLC, Platelet, ESR, Peripheral smear examination

13 1395 Platelet count

14 1396 Reticulocyte count

15 1397 Absolute Eosinophil count

16 1398 Packed Cell Volume (PCV)

17 1399 Peripheral Smear Examination

18 1400 Smear for Malaria parasite

19 1401 Bleeding Time

20 1402 Osmotic fragility Test

21 1403 Bone Marrow Smear Examination

22 1404 Bone Marrow Smear Examination with iron stain

23 1405 Bone Marrow Smear Examination and cytochemistry

24 1406 Activated partial ThromboplastinTime (APTT)

25 1407 Rapid test for malaria(card test)

26 1408 WBC cytochemistry for leukemia -Complete panel

27 1409

Bleeding Disorder panel- PT, APTT, Thrombin Time Fibrinogen, D-Dimer/ FDP

28 1410 Factor Assays-Factor VIII

29 1411 Factor Assays-Factor IX

30 1412 Platelet Function test

31 1413

Tests for hypercoagulable states- Protein C, Protein S, Antithrombin

32 1414 Tests for lupus anticoagulant

33 1415

Tests for Antiphospholipid antibody IgG, IgM ( for cardiolipin and B2 Glycoprotein 1)

34 1416 Thalassemia studies (Red Cell indices and Hb HPLC)

35 1417 Tests for Sickling / Hb HPLC)

LABORATORY MEDICINE / BLOOD BANK

36 1418 Blood Group & RH Type

37 1419 Cross match

38 1420 Coomb’s Test Direct

39 1421 Coomb’s Test Indirect

40 1422 3 cell panel- antibody screening for pregnant female

41 1423 11 cells panel for antibody identification

42 1424 HBs Ag

43 1425 HCV

44 1426 HIV I and II

45 1427 VDRL

46 1428 RH Antibody titer

47 1429 Platelet Concentrate

48 1430 Random Donor Platelet(RDP)

49 1431 Single Donor Platelet (SDP- Aphresis)

LABORATORY MEDICINE / HISTOPATHOLOGY

50 1432 Routine-H & E

51 1433 special stain

52 1434 Immunohistochemistry(IHC)

53 1435 Frozen section

54 1436 Paraffin section

LABORATORY MEDICINE / CYTOLOGY

55 1437 Pap Smear

56 1438 Body fluid for Malignant cells

57 1439 FNAC

NAME OF INVESTIGATION / FLOW CYTOMETRY

58 1440 Leukemia panel /Lymphoma panel

59 1441 PNH Panel-CD55,CD59

LABORATORY MEDICINE / CYTOGENETIC STUDIES

60 1442 Karyotyping

61 1443 FISH

LABORATORY MEDICINE / BIO-CHEMISTRY

62 1444 Blood Glucose Random

63 1445 24 hrs urine for Proteins,Sodium, creatinine

64 1446 Blood Urea Nitrogen

65 1447 Serum Creatinine

66 1448 Urine Bile Pigment and Salt

67 1449 Urine Urobilinogen

68 1450 Urine Ketones

69 1451 Urine Occult Blood

70 1452 Urine total proteins

71 1453 Rheumatoid Factor test

72 1454 Bence Jones protein

73 1455 Serum Uric Acid

74 1456 Serum Bilirubin total & direct

75 1457 Serum Iron

76 1458 C.R.P.

77 1459 C.R.P Quantitative

78 1460 Body fluid (CSF/Ascitic Fluid etc.)Sugar, Protein etc.

79 1461 Albumin.

80 1462 Creatinine clearance.

81 1463 Serum Cholesterol

82 1464 Total Iron Binding Capacity

83 1465 Glucose (Fasting & PP)

84 1466 Serum Calcium –Total

85 1467 Serum Calcium –Ionic

86 1468 Serum Phosphorus

87 1469 Total Protein Alb/Glo Ratio

88 1470 IgG.

89 1471 IgM.

90 1472 IgA.

91 1473 ANA.

92 1474 Ds DNA.

93 1475 S.G.P.T.

94 1476 S.G.O.T.

95 1477 Serum amylase

96 1478 Serum Lipase

97 1479 Serum Lactate

98 1480 Serum Magnesium

99 1481 Serum Sodium

100 1482 Serum Potassium

101 1483 Serum Ammonia

102 1484 Anemia Profile

103 1485 Serum Testosterone

104 1486 Imprint Smear From Endoscopy

105 1487 Triglyceride

106 1488 Glucose Tolerance Test (GTT)

107 1489 Triple Marker.

108 1490 C.P.K.

109 1491 Foetal Haemoglobin (HbF)

110 1492 Prothrombin Time (P.T.)

111 1493 L.D.H.

112 1494 Alkaline Phosphatase

113 1495 Acid Phosphatase

114 1496 CK MB

115 1497 CK MB Mass

116 1498 Troponin I

117 1499 Troponin T

118 1500 Glucose Phosphate Dehydrogenase (G, 6PD)

119 1501 Lithium.

120 1502 Dilantin (phenytoin).

121 1503 Carbamazepine.

122 1504 Valproic acid.

123 1505 Feritin.

124 1506 Blood gas analysis

125 1507 Blood gas analysis with electrolytes

126 1508 Urine pregnancy test

127 1509 Tests for Antiphospholipid antibodies syndrome.

128 1510 Hb A1 C

129 1511 Hb Electrophoresis/ Hb HPLC

130 1512 Kidney Function Test.

131 1513 Liver Function Test.

132 1514 Lipid Profile.( Total cholesterol,LDL,HDL,treigylcerides)

Nutritional Markers

133 1515 Serum Iron

134 1516 Total Iron Binding Capacity

135 1517 Serum Ferritin

136 1518 Vitamin B12 assay.

137 1519 Folic Acid assay.

138 1520

Extended Lipid Profile.( Total cholesterol,LDL, HDL,treigylcerides,Apo A1,Apo B,Lp(a) )

139 1521 Apo A1.

140 1522 Apo B.

141 1523 Lp (a).

142 1524 CD 3,4 and 8 counts

143 1525 CD 3,4 and 8 percentage

144 1526 LDL.

145 1527 Homocysteine.

146 1528 HB Electrophoresis.

147 1529 Serum Electrophoresis.

148 1530 Fibrinogen.

149 1531 Chloride.

150 1532 Magnesium.

151 1533 GGTP.

152 1534 Lipase.

153 1535 Fructosamine.

154 1536 β2 microglobulin

155 1537 Catecholamines.

156 1538 Creatinine clearance.

NAME OF INVESTIGATION / TUMOUR MARKERS

157 1539 PSA- Total.

158 1540 PSA- Free.

159 1541 AFP.

160 1542 HCG.

161 1543 CA. 125.

162 1544 CA 19,9.

163 1545 CA 15.3.

164 1546 Vinyl Mandelic Acid

165 1547 Calcitonin

166 1548 Carcioembryonic antigen(CEA)

OTHERS

167 1549 Immunofluorescence

168 1550 Direct(Skin and kidney Disease)

169 1551 Indirect (antids DNA Anti Smith ANCA)

170 1552 VitD3 assay

171 1553

Serum Protein electrophoresis with immunofixationelectrophoresis (IFE)

172 1554 BETA-2 Microglobulin assay

173 1555 Anti cycliocitrullinated peptide (Anti CCP)

174 1556 Anti tissuetransglutaminase antibody

175 1557 Serum Erythropoetin

176 1558 ACTH

HARMONES

177 1559 T3, T4, TSH

178 1560 T3

179 1561 T4

180 1562 TSH

181 1563 LH

182 1564 FSH

183 1565 Prolactin

184 1566 Cortisol

185 1567 PTH(Paratharmone)

186 1568 C-Peptide.

187 1569 Insulin.

188 1570 Progesterone.

189 1571 17-DH Progesterone.

190 1572 DHEAS.

191 1573 Androstendione.

192 1574 Growth Hormone.

193 1575 TPO.

194 1576 Throglobulin.

195 1577 Hydatic Serology.

196 1578 Anti Sperm Antibodies.

197 1579 Qualitative.

198 1580 Quantitative.

199 1581 Qualitative.

197 1582 HPV serology

198 1583 Rota Virus serology

199 1584 PCR for TB

200 1585 PCR for HIV

201 1586 Chlamydae antigen

202 1587 chlamydae antibody

203 1588 Brucella serology

204 1589 Influenza A serology

205 1726 Anti MUSK body titre

206 1727 Serum COPPER

207 1728 Serum ceruloplasmin

208 1729 Urinary copper

209 1730 Serum homocystine

210 1731 Serum valproate level

211 1732 Serum phenol barbitone level

212 1733 Coagulation profile

213 1734 Protein C, S anti thrombine – III

214 1735 Serum lactate level

CSF

215 1736

Basic studies including cell count, protein, sugar, gram stain, India Ink preparation and smear for AFP

216 1737 Special studies

217 1738 PCR for tuberculosis/ Herpes simplex

218 1739 Bacterial culture and sensitivity

219 1740 Mycobacterial culture and sensitivity

220 1741 Fungal culture

221 1742 Malignant cells

222 1743 Anti measles antibody titre (with serum antibody titre)

223 1744 Viral culture

224 1745

Antibody titre (Herpes simplex, cytomegalo virus, flavivirus, zoster varicella virus)

225 1746 Oligoclonal band

226 1747 Myelin Basic protein

227 1748 Lactate

228 1749 Crypto coccal antigen

TESTS IN GASTRO-ENTEROLOGY

229 1750 D-xylase test

230 1751 Fecal fat test/ fecal chymotrypsin/ fecal elastase

231 1752 Breath tests

232 1753 H pylori serology for ciliac disease

233 1754 HBV genotyping

234 1755 HCV genotyping

TESTS IN ENDOCRINOLOGY ( IN ADDITION TO THOSE INCLUDED UNDER HARMONES)

235 1756 Urinary VMA

236 1757 Urinary metanephrine/Normetanephrine

237 1758 Urinary free catecholamine

238 1759 Serum catecholamine

239 1760 Serum aldosterone

240 1761 24 Hr urinary aldosterone

241 1762 Plasma renin activity

242 1763 Serum aldosterone/renin ratio

243 1764 Osmolality urine

244 1765 Osmolality serum

245 1766 Urinary sodium

246 1767 Urinary Chloride

247 1768 Urinary potassium

248 1769 Urinary calcium

249 1770 Thyroid binding globulin

250 1771 24 hr. urinary free cotisole

251 1772 Islet cell antebody

252 1773 GAD antibody

253 1774 Insulin associated antibody

254 1775 IGF-1

255 1776 IGF-BP3

256 1777 Sex hormone binding globulin

257 1778 USG guided FNAC thyroid gland

258 1779 E2

259 1780 Thyro globulin antibody

The items which are not covered under CGHS

S.No Investigations Rate

1 HCV - RNA viral load - Qualitative

2 HCV - RNA viral load - Quantitative

3 HBV - DNA viral load - Qualitative

4 HBV - DNA viral load - Quantitative

5 Serum Electrophoresis - M proteins

6 Serum Free Testosterone

7 Pleural Fluid ADA- Adenosin Deaminase

8 Ascitic Fluid for ADA-Adenosin Deaminase

9 Urine - Culture & Sensitivity (Automated)

10 Blood Culture & Sensitivity

11 Dengue Antibodic IGG

12 Dengue Antibodies IgM

13 Leptospira IgM Antibody (ELISA)

14 Hepatitis B Surface Antibodies

15 Anti HBe

16 HBeAg

17 Herpes Simplex Virus(HSV) I - IgG & IgM

18 Herpes Simplex Virus (HSV) II - IgG & IgM

19 Oesterogen Receptor Progesterone Receptor(ER/PR) Assay(Tissue Sample)

20 Stone Analysis - Bio Chemical Method

21 IgM for Cickungunya

22 Serum Transferrin level (Saturation)

23 Anti HAV - IGM &Total

24 Anti HAV - IGM

25 Anti HEV IGM

26 Antibodies Titre - Hepatitis B (Anti HBs)

27 Asctiic Fluid ADA

28 Compelement C3 & C4 Levels

29 ENA Screening (Extractable Nuclear Antigen Antibody)

30 Fungal Staining

31 H1N1 - RT - PCR

32 HER -NEU 2

33 HLA B 27

34 P4 & E2 ( Estradiol to progesterone ratio)

35 Dengu NS1 Ag

36 QTP- -Gold & HLA B27

37 Quantiferan TB Gold Test

38 Serum IgE Level

39 Serum ACE Level

40 Sr.Acetyl Cholinesterase

41 Urine - PCR

42 Urine pH

43 Widal

44 Scrub Typhus IgM

45 Anti HBc(Total)

46 Thphi Dot IgM

47 Myelo Peroxidase

48 Histopathology of Bipsy /Specimen- Small

49 Histopathology of Specimen- Medium

50 Histopathology of Specimen-Large

51 HBc IgM

52 Sputum AFB (3 Specimen)