Registration Form for HCEs.pdf

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APPLICATION FOR REGISTRATION OF HEALTHCARE SERVICE PROVIDERS Healthcare Service Provider is required to complete this form as per the requirements of the provisions of Punjab Healthcare Commission Act 2010. Incomplete forms will not be entertained. Provision of incorrect information/documents will result in rejection of the Application. Return the completed form to: Directorate of Licensing & Accreditation, Punjab Healthcare Commission Office # 1 & 2, 4 th Floor Shaheen Complex, 38-Abbot Road, Lahore Questions regarding completion of this application may be directed to: Ph. 042 36376371 - 8 For further information, please visit our web site: www.phc.org.pk A. HEALTHCARE SERVICE PROVIDER Name: Name of CC Supervisor/Manager, who has got phlebotomy training certificate from any Govt. institution or from SKM Designation: _________________________ Status: Owner Manager In-charge Qualification (attach copy of degree/diploma): kindly provide CC Supervisor/Manager qualification details CNIC Number: Registration No. PMDC/ PNC/ NCH/ NCT (attach copy of registration certificate): if CC Supervisor/Manager has any membership of above mention bodies Mailing Address: CC mail address Town: City: District: Punjab Telephone (landline & mobile) Fax: Email: B. HEALTHCARE ESTABLISHMENT Name: Shaukat Khanum Laboratory Collection Centre Date of establishment at present location: (Day/Month/Year) Date of agreement Previous Name (If any): N/A Mailing Address: CC address Town: City: District: Punjab Telephone (landline & mobile) Fax: Email:

Transcript of Registration Form for HCEs.pdf

  • APPLICATION FOR REGISTRATION

    OF HEALTHCARE SERVICE PROVIDERS

    Healthcare Service Provider is required to complete this form as per the requirements of the

    provisions of Punjab Healthcare Commission Act 2010.

    Incomplete forms will not be entertained.

    Provision of incorrect information/documents will result in rejection of the Application.

    Return the completed form to:

    Directorate of Licensing & Accreditation,

    Punjab Healthcare Commission

    Office # 1 & 2, 4th Floor Shaheen Complex, 38-Abbot Road,

    Lahore

    Questions regarding completion of this application may be directed to: Ph. 042 36376371 - 8

    For further information, please visit our web site: www.phc.org.pk

    A. HEALTHCARE SERVICE PROVIDER

    Name: Name of CC Supervisor/Manager, who has got phlebotomy training certificate from any Govt. institution or from SKM

    Designation: _________________________

    Status: Owner Manager In-charge

    Qualification (attach copy of degree/diploma): kindly provide CC Supervisor/Manager qualification details

    CNIC Number:

    Registration No. PMDC/ PNC/ NCH/ NCT (attach copy of registration certificate): if CC Supervisor/Manager has any membership of above mention bodies

    Mailing Address: CC mail address

    Town:

    City: District: Punjab

    Telephone (landline & mobile)

    Fax: Email:

    B. HEALTHCARE ESTABLISHMENT

    Name: Shaukat Khanum Laboratory Collection Centre Date of establishment at present location: (Day/Month/Year) Date of agreement

    Previous Name (If any): N/A

    Mailing Address: CC address

    Town:

    City: District: Punjab

    Telephone (landline & mobile)

    Fax: Email:

    PcworldTypewriter

    PcworldTypewriterCC SUPERVISOR

    PcworldTypewriter34201-0339847-7

    PcworldTypewriterCommonwealth MBA Management(AIOU),CRCP (DUHS)HHSM (DUHS)CQP (PIQC) MLT (PMF) MLA (PMF)

    PcworldTypewriter

    PcworldTypewriterSHAUKAT KHANUM MEMORIAL CANCER HOSPITAL AND LABORATORY COLLECTION CENTRE BHIMBER ROAD GUJRAT

    PcworldTypewriterBHIMBER ROAD

    PcworldTypewriter

    PcworldTypewriterGUJRAT

    PcworldTypewriter053-3605473

    PcworldTypewriter

    PcworldTypewriter

    PcworldTypewriterNA

    [email protected]

    PcworldTypewriter

    PcworldTypewriterSHAUKAT KHANUM MEMORIAL CANCER HOSPITAL AND LABORATORY COLLECTION CENTRE BHIMBER ROAD GUJRAT

    PcworldTypewriterBHIMBER ROAD

    PcworldTypewriterGUJRAT

    PcworldTypewriter053-3605473

    PcworldTypewriterNA

    [email protected]

    PcworldTypewriter01-11-1999

    PcworldTypewriter

  • C. TYPE OF ORGANIZATION

    Type of Ownership (please check the appropriate box)

    Government Others

    District Government Sole Proprietary Voluntary Non- Profit

    Provincial Government* Partnership Association

    Federal Government Corporation Limited Liability Company (Private)

    Autonomous Institution Trust Limited Liability Company (Public)

    CMH/ Cantonment Hospital

    If incorporated or registered, date of incorporation/No & organization it is registered with:

    *Provincial government includes Social Security, Auqaf department & family planning department etc

    D. TYPE OF HEALTHCARE ESTABLISHMENT (please check the relevant box) Teaching Non-Teaching Single Specialty (please specify): _____________________________________________________ Multiple Specialty Others GP Clinic/ Homeopath/ Hakim/ Lab/ Radiological or Imaging/Maternity or Nursing homes/ Dental clinic/ Cosmetic Surgery/ Laser Clinic/ If any other please specify: _Collection Centre___

    E. BED STRENGTH

    Number of Beds: ____N/A________

    ATTESTATION

    I, the undersigned, do hereby solemnly affirm and declare that the information provided above is

    true and correct to the best of my knowledge and belief and that nothing has been concealed

    therefrom. I also state that if any false or incorrect information is provided to the Commission, it

    may result in rejection of my application for registration and I may also be found liable to pay fine to

    the Commission.

    Signature to be filled by SKM Name of Applicant

    Date

    Designation

    PcworldTypewriter

    PcworldTypewriterFRANCHISE

    PcworldTypewriter

    PcworldTypewriterSYED FARHAN SHAH

    PcworldTypewriter

    PcworldTypewriterCC SUPERVISOR

    PcworldTypewriter02-04-2015

    PcworldTypewriter

  • Annexure A: Information Regarding Staff

    CC Employee Name Designation

    Training Dates

    Contact Number

    From Date To Date

    PcworldTypewriterSYED FARHANSHAH

    PcworldTypewriter

    PcworldTypewriterM RAMZAN

    PcworldTypewriter

    PcworldTypewriterUNFAWAN ULLAHLATIF

    PcworldTypewriter

    PcworldTypewriter

    PcworldTypewriterSULMAN SHABEER

    PcworldTypewriter

    PcworldTypewriter

    PcworldTypewriter

    PcworldTypewriter

    PcworldTypewriterSULMAN NAWAZ

    PcworldTypewriterMUSHTAQ MASHI

    PcworldTypewriterCC SUPERVISOR

    PcworldTypewriterPHLEBOTOMIST

    PcworldTypewriter

    PcworldTypewriterPHLEBOTOMIST

    PcworldTypewriterPHLEBOTOMIST

    PcworldTypewriterCC COURIER

    PcworldTypewriterSWEEPER

    PcworldTypewriterTARA JAVAID

    PcworldTypewriterCC COURIER LHR

    PcworldTypewriter0343-6245600

    PcworldTypewriter0334-3523273

    PcworldTypewriter0300-6251394

    PcworldTypewriter0312-7607636

    PcworldTypewriter0331-6372919

    PcworldTypewriter0344-6202592

    PcworldTypewriter0321-4228402

    PcworldTypewriter

    PcworldTypewriter

    PcworldTypewriter

    PcworldTypewriter

    PcworldTypewriter(21-06-2002) TO (25-06-2002)

    PcworldTypewriter

    PcworldTypewriter

    PcworldTypewriter(30-10-2014) TO (31-10-2014)

    PcworldTypewriter(23-10-2014) TO (24-10-2014)

    PcworldTypewriter

    PcworldTypewriter(04-02-2002) TO (08-02-2002)(28-05-2001) (01-06-2001)

    PcworldTypewriter

    PcworldTypewriter

    PcworldTypewriter

    PcworldTypewriter

    PcworldTypewriter

    PcworldLine

    PcworldLine

    PcworldLine

    PcworldLine

    PcworldTypewriter

    PcworldTypewriter

    PcworldTypewriter

    PcworldTypewriter


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