MRI Centre Registration
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Service Provider Enrolment Form
Basic Information
MRI Centre Registration Requirements
Fields marked with * are mandatory.
District
Select District
Agra
Aligarh
Ambedkar Nagar
Amethi
Amroha
Auraiya
Ayodhya
Azamgarh
Baghpat
Bahraich
Ballia
Balrampur
Banda
Barabanki
Bareilly
Basti
Bhadohi
Bijnor
Budaun
Bulandshahr
Chandauli
Chitrakoot
Deoria
Etah
Etawah
Farrukhabad
Fatehpur
Firozabad
Gautam Buddha Nagar
Ghaziabad
Ghazipur
Gonda
Gorakhpur
Hamirpur
Hapur
Hardoi
Hathras
Jalaun
Jaunpur
Jhansi
Kannauj
Kanpur Dehat
Kanpur Nagar
Kasganj
Kaushambi
Kheri
Kushinagar
Lalitpur
Lucknow
Maharajganj
Mahoba
Mainpuri
Mathura
Mau
Meerut
Mirzapur
Moradabad
Muzaffarnagar
Pilibhit
Pratapgarh
Prayagraj
Raebareli
Rampur
Saharanpur
Sambhal
Sant Kabir Nagar
Shahjahanpur
Shamli
Shrawasti
Siddharthnagar
Sitapur
Sonbhadra
Sultanpur
Unnao
Varanasi
District is required.
Name of Diagnostic Centre / Service Provider
Diagnostic centre name is required.
Name of Owner / Authorized Person
Owner / Authorized Person name is required.
Health Facility Registry ID (HFR)
HFR ID is required.
Contact & Address
Contact Details and Complete Address
Mobile Number 1
+91
Mobile Number 1 is required.
Enter a valid 10 digit Indian mobile number.
Mobile Number 2
+91
Enter a valid alternate mobile number.
Email ID
Email ID is required.
Enter a valid email address.
Complete Address
Complete address is required.
City
City is required.
State
State is required.
Pin Code
Pin Code is required.
Enter a valid 6 digit pin code.
Regulatory Details
PCPNDT and License / Regulatory Documents
PCPNDT Registration Number
PCPNDT Registration Number is required.
PCPNDT Validity Period
PCPNDT validity date is required.
PCPNDT document upload
Clinical Establishment Registration No. & Date
Clinical Establishment Registration No. & Date is required.
Clinical Establishment Validity Period
Clinical validity date is required.
Clinical Establishment
Undertaking
Declaration and Authorized Signatory
I/We undertake to comply with all Government guidelines and certify that the information and documents submitted are true and valid.
Please accept the undertaking.
Authorized Signatory Name
Authorized Signatory Name is required.
Designation
Designation is required.
Sign and Stamp Upload
Submission Date
Bank & Documents
Bank Details and Supporting Documents
Bank Details (VPA Number)
Preferred Settlement Contact
Registration Certificates *
License and regulatory documents
Address Proof *
Electricity bill, property tax receipt, rent agreement, utility bill or government address proof
Owner / Signatory ID Proof *
Government-issued ID proof
Other Relevant Documents
Any additional supporting document