Nhis Registration Form PDF Details

The National HIV/AIDS Strategy (NHAS) was released by the Obama administration in 2010 with the goal of reducing HIV incidence, increasing access to care and treatment, and reducing health disparities among populations most affected by HIV. To help achieve these goals, the NHAS calls for a system-wide approach to fighting HIV that engages key stakeholders including people living with HIV, their families and communities, healthcare providers, state and local governments, and private sector partners. One important tool for achieving this goal is the Nhis Registration Form . . .

You will find information about the type of form you wish to complete in the table. It will show you just how long it will need to finish nhis registration form, exactly what fields you need to fill in and several additional specific details.

QuestionAnswer
Form NameNhis Registration Form
Form Length4 pages
Fillable?Yes
Fillable fields123
Avg. time to fill out25 min 40 sec
Other namesnhisonline com, nhisonline, nhis portal, https 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 nhisonline com 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 nhisonline com 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:

nhisonline com empty fields to fill out

You should type in the data inside the section Registration, Number Date, Registered and Date, Last, Renewal

Entering details in nhisonline com stage 2

The system will demand you to present particular essential info to conveniently fill out the area Address, i, Name, ii, Position and iii, Contact, number, cellphone

Address, iNameiiPosition, and iiiContactnumbercellphone in nhisonline com

The Institution, Qualification, Date, vi, Dental, ix, Laboratory and If, xv, above, is, applicable, please, specify field is the place where either side can describe their rights and obligations.

part 4 to filling out nhisonline com

End by taking a look at the next areas and completing them correspondingly: Details, of, Bank, Account Key, Professional, Staff Type, of, Professional Medical, Practitioners and Number.

stage 5 to entering details in nhisonline com

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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