Nhis Registration Form PDF Details

The NHIS Registration Form is a comprehensive document required for the accreditation of health care facilities, encompassing a wide range of information from basic facility identification to detailed staff credentials. This form is carefully structured to capture essential data, including the name and type of the health care facility with options ranging from CHPS Compound to Tertiary Hospitals and Pharmacies, indicating the diverse scope of facilities that can apply. Facility ownership is also categorized, highlighting the inclusive approach of the NHIS to government, mission, quasi-government, and private establishments. The form takes into consideration the status of the application, distinguishing between new applications, renewals, upgrades, and re-accreditations. It mandates the registration of the company and health facility with regulatory bodies, ensuring legality and compliance. Moreover, detailed information regarding the address, chief executive, and services offered is required, showcasing the form's role in ensuring that facilities meet specific operational standards. The form also delves into the financial aspects by asking for bank details, underscoring the economic viability of the facility. Sections dedicated to professional staff and necessary attachments signify the importance of qualified personnel and proper documentation in the accreditation process. Lastly, the inclusion of a declaration by the chief executive or proprietor underscores the accountability and responsibility inherent in the submission of accurate information.

QuestionAnswer
Form NameNhis Registration Form
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesnhis login, how to register nhis on phone, nhis apply online, nhisonline com ng

Form Preview Example

NHIS-F2

SERIAL NO…

ACCREDITATION OF HEALTH CARE FACILITY

APPLICATION FORM

1.Name of health care facility -------------------------------------------------------------------------------

2.Type of Facility. Tick the appropriate box:

a) □ CHPS Compound

b) □ Maternity Home

c)

□ Health Centre

d) □ Clinic

e)

□ Polyclinic

f) □ Primary Hospital

g)

□ Secondary Hospital

h) □ Tertiary Hospital

i) □ Pharmacy

j) □ Chemical Shop

k)

□ Laboratory

l) □ Ultrasound Scan Centre

m)□ Other

3.Facility Ownership. Tick the appropriate box:

a) □ Government

b) □ Mission

c)

□ Quasi-Government

d) □ Private

4. Category of Application. Tick the appropriate box:

a) □ New Application

b) □ Renewal

c)

□ Upgrade

d) □ Re-accreditation

e)□ Other………………………

5.Registration of company with Registrar General’s Department:

Business Registration Number

Date Registered

Date Last Renewal

6. Registration of health facility with appropriate regulatory body/bodies:

Regulatory Body

Registration Number

Date

Date Last

Registered

Renewal

 

 

7. Address:

Street address/Location

Postal address

Town/City

District

Region

Tel number

Cell phone number

Fax number

Email

Website

8.Chief Executive/ Administrator/ Proprietor:

i.Name -----------------------------------------------------------------------------------------------------------

i i. Position----------------------------------------------------------------------------------------------------------

iii.Contact number (cell phone) ---------------------------------------------

vi. Qualifications

Institution

Qualification

Date

 

 

 

 

 

 

 

 

 

 

 

 

9.Services offered tick the appropriate box:

i. □ Out-patient

ii. □ In-patient (24hours)

iii. □ Maternity

iv. □ Surgery

v. □ Ophthalmology

vi. □ Dental

vii. □ Pharmacy

viii. □ Chemical shop

ix. □ Laboratory

x. □ Ultrasound scan

xi. □ Diagnostic X-ray

xii. □ CT scan

xiii. □ Pathology (Specialist)

xiv. □ Orthopaedics (Specialist)

xv. □ Other

9b. If xv. above is applicable, please specify:

…………………………………………………………………………………………

……………………………………………………………………………………

………………………………………………………………………………………

10. Details of Bank Account

a. Bankers…………………………………………. b. Branch……………………………..

c. Account Name……………………………………………………………………….

d. Account Number……………………………………………………………………..

11. Key Professional Staff

Type of Professional

Medical Practitioners

Nurses

Midwives

Nurse-Midwives

Pharmacists

Number

Dispensing Technicians

Laboratory Technologist

Laboratory Technicians

Radiographers/X-ray Technicians

Medical Assistants

Doctor Anaesthetist

Nurse Anaesthetists

Dentists

Ophthalmologists

Other (Please specify)

12. Attachments

Please attach copies of the following to your completed Application Form:

a.Certificate of Registration of your facility with the Registrar General’s Department

b.Certificate of Registration of your facility with appropriate regulatory body/bodies

c.Proof of retention of your facility with regulatory body/bodies

d.Certificate of qualification of heads of departments/units

e.Proof of retention of heads of departments/units with regulatory body/bodies where applicable

f.PIN of nurses/midwives where applicable

g.List of names of all professional staff, indicating whether they are full-time or part- time. Please use the format shown below.

h.Receipt of payment of applicable Accreditation Application fee.

13. Format for listing names of professional staff (See g. under 12 above)

Please use the following format to list your professional staff.

Name of Professional Rank / Position

Please tick whether

 

permanent or temporary

If temporary /locum,

 

 

permanent place of

Permanent

Temporary/locum

work

 

 

 

14. Declaration

I, ……………………………...………………………………………., the Chief Executive/

Administrator/Proprietor of ………………………………………………………………….

hereby declare that the information given above is correct and that I will be responsible for any falsehood provided.

Signature ………………….…………… Date ……………………………

OFFICIAL USE ONLY

Received by…………………………………………………………………..

Receipt No……………………………………………………………………..

Signature of Officer………………………… Date………………….

How to Edit Nhis Registration Form Online for Free

Couple of things are simpler than filling in forms taking advantage of this PDF editor. There is not much for you to do to enhance the nhisenrolment ng file - simply adopt these measures in the next order:

Step 1: Click on the button "Get Form Here".

Step 2: When you've accessed the nhisenrolment ng editing page you may notice all of the options you'll be able to undertake regarding your file within the top menu.

The particular sections will help make up the PDF document:

nhis login empty fields to fill out

You should type in the data inside the section Business Registration Number, Date Registered, Date Last Renewal, Registration of health facility, Regulatory Body, Registration Number, Date Registered, and Date Last Renewal.

Entering details in nhis login stage 2

The system will demand you to present particular essential info to conveniently fill out the area Address, Street addressLocation Postal, Chief Executive Administrator, i Name, i i Position, iii Contact number cell phone, vi Qualifications, Institution, Qualification, and Date.

Address, Street addressLocation Postal, Chief Executive Administrator, i Name, i i Position, iii Contact number cell phone, vi Qualifications, Institution, Qualification, and Date in nhis login

The Services offered tick the, ii Inpatient hours iii Maternity, v Ophthalmology, vi Dental, vii Pharmacy, viii Chemical shop, ix Laboratory, x Ultrasound scan xiii Pathology, xi Diagnostic Xray xii CT scan, and If xv above is applicable please field is the place where either side can describe their rights and obligations.

part 4 to filling out nhis login

End by taking a look at the next areas and completing them correspondingly: Details of Bank Account, a Bankers b Branch, c Account Name, d Account Number, Key Professional Staff, Number, Type of Professional, Medical Practitioners, Nurses, Midwives, and NurseMidwives.

stage 5 to entering details in nhis login

Step 3: As soon as you press the Done button, your finished file can be simply exported to each of your devices or to electronic mail stated by you.

Step 4: Have at least two or three copies of your file to prevent any specific upcoming challenges.

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