SFRD National Care Alliance - Tertiary Care Hospital Partnership Onboarding Form

Section A: Institutional Identity & Contact Information

SFRD invites your institution to become a pillar of our National Care Alliance. Your hospital's expertise is vital to building rare disease care pathways.

Full Legal Name of Hospital *

Type of Institution *

Date of Inception *

Official Website URL *

Social Media Handles *

Headquarters Address *

Nodal Officer for SFRD Partnership *

Nodal Officer's Designation *

Official Contact Email *

Official Contact Phone *

Unique Hospital Identifier

Section B: Legal, Structural & Accreditations

This information helps us understand your hospital's governance and quality standards.

Key Office Bearers

Provide details for your primary contact persons.

Office Bearer 1

Name

Designation

Phone

Geographical Presence *

Section C: Operational Capacity & Expertise

Help us understand the scale and scope of your clinical services.

Total Bed Capacity *

Number of Full-Time Staff *

List of Medical Specialities *

Advanced Equipment & Facilities *

Future Plans / Expansions

Section D: The SFRD Partnership — Building a Centre of Care

Our partnership is centered on a mutual commitment to rare disease care.

1. Capacity Building Agreement: Yes, our institution agrees to partner with SFRD on a capacity-building program for our teams.2. Priority Care Commitment: We agree to treat all SFRD-referred patients on a priority basis.

3. Concessional Services Commitment: We agree to offer preferential rate cards for all SFRD-referred patients.

Upload the proposed rate card or specify the discount structure.

4. Digital Integration: We will assign a nodal officer to manage digital referrals and provide updates on patient status.

How else can we collaborate?

Select other ways you would be interested in contributing.

Joint Diagnostic & Health Camps: Co-hosting camps for undiagnosed patients.Research & Clinical Trials: Collaborate as a site for future rare disease research and trials.Policy Advocacy: Join SFRD in advocating for better healthcare policies for rare diseases.Patient Education: Co-create and disseminate educational materials for patients and clinicians.

Section E: Consent & Formal Agreement

This agreement formalizes our strategic partnership. Please have an authorized representative complete this section.

I confirm that I am an authorized representative of the hospital named in this form.I understand that this partnership is voluntary and collaborative. We can end our association with 60 days' written notice.I consent to SFRD securely storing our hospital's information and listing us in its public directory of trusted care partners.Patient Data Confidentiality: We will handle all patient data with the strictest confidentiality, in compliance with applicable regulations.I confirm that all the information provided is accurate to the best of my knowledge.

Full Name of Authorized Representative *

Designation *

Date

Digital Signature *