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?No
Fillable fields0
Avg. time to fill out1 min
Other nameshow to register for nhis, nhis form, nhis login, 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………………….

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