Application 2

 

APPLICATION FOR LICENSE

FOR HEALTHCARE ESTABLISHMENTS

 

Healthcare Establishments are 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 FloorShaheen Complex38-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

 

.

GENERAL  INFORMATION

.

HEALTHCARE SERVICE PROVIDER

Name:

Designation: _________________________

 

Status:     Owner  Manager  In-charge

Qualification:

 

 

CNIC Number:

 

Registration No. PMDC/ PNC/ NCH/ NCT:

 

Mailing Address:

 

 

Town:

 

City:

District:                                Punjab

Telephone (landline & mobile)

 

Fax:

Email:

.

HEALTHCARE ESTABLISHMENT

Name:

Date of establishment at present Location:

(Day/Month/Year)

 

Previous Name (If any):

Mailing Address:

Town:

City:

District:                              Punjab

Telephone:(landline & mobile)

Fax:

Email:

.

TYPE OF ORGANISATION

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:

 

 

License No. (if any):

 

.

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: _____________________

 

.

EXTERNAL VALIDATION

List all applicable external certificates, licenses, accreditation and similar Awards/ Certificate

£ Agency________________________________          £Award ___________________________________

£ Agency________________________________          £Award ___________________________________

£ Agency________________________________          £Award ___________________________________

£ Agency________________________________          £Award____________________________________

 

 

.

SERVICES PROVIDED BY THE HEALTHCARE ESTABLISHMENT

Check the type of services that are provided, Attach additional pages if necessary 

Check if provided

Service

Check if provided

Service

 

 

Medical

 

 

Surgical

 

 

 

 

 

 

£

 

Burns  

£

 

Cardiac

£

 

Cardiology  

£

 

Day surgery

£

 

Communicable diseases

£

 

ENT

£

 

Dermatology

£

 

Facio-maxillary

£

 

Ear Nose & Throat  

£

 

General

£

 

Endocrinology  

£

 

Gynae

£

 

Gastrointestinal

£

 

Head and neck

£

 

General  

£

 

Joint replacement

£

 

Genetics  

£

 

Neurosurgery

£

 

Genitourinary

£

 

Obstetric

£

 

Geriatrics

£

 

Ophthalmological

£

 

Haematology

£

 

Orthopaedic

£

 

Hepatology

£

 

Paediatric surgery

£

 

Neonatology

£

 

Plastic and reconstructive

£

 

Neurology

£

 

Thoracic

£

 

Oncology

£

 

Transplant

£

 

Ophthalmology

£

 

Urology

£

 

Paediatric

£

 

Vascular

£

 

Pain management

£

 

 

£

 

Palliative care

£

 

Others

£

 

Pulmonary

£

 

 

£

 

Renal

£

 

Additional Specialized Areas

£

 

Renal dialysis

£

 

Blood Bank Services  

£

 

Rheumatology

£

 

Chiropody

£

 

Reproductive

£

 

Chiropractic

£

 

 Other

£

 

Clinical Psychology

£

 

 

£

 

Nutrition

£

 

Ambulance

£

 

Drug and Alcohol

£

 

Community/home based care/immunization

£

 

General Dental

£

 

Emergency

£

 

Inpatient Pharmacy

£

 

Hospice

£

 

Laboratory – Biochemical

£

 

Long Term Care Unit

£

 

Laboratory- Haematology

£

 

Maternity

£

 

Laboratory –Histopathology

£

 

Poly Trauma

£

 

Laboratory – Microbiology

£

 

Primary Care

£

 

Limbs and Prosthetics

£

 

Self Care Unit/Independent Living Facility

£

 

Orthognathic

£

 

Psychiatry

£

 

Outpatient Pharmacy

£

 

Social Work

£

 

Periodontal

£

 

Homeopathy

£

 

Physical therapy rehabilitation

£

 

Allied Health

£

 

Prosthetic dental

£

 

Speech therapy

£

 

Radiology/Imaging (diagnostic)

£

 

Others

£

 

Radiology (therapeutic/intervention)

 

.

BED CAPACITY

Please read the explanatory note below. Indicate the total number of beds or treatment spaces actually set up and operational for patient care.  If beds are unisex just indicate the total.

                       Number of Beds

  Male

      Female

          Total

1.

Medical

 

 

 

2.

Surgical

 

 

 

3.

Intensive Care

 

 

 

4.

Neonatal

 

 

 

5.

Operating Room

 

 

 

6.

Emergency Room

 

 

 

7.

Others (Please specify)

 

 

 

                    Total

 

 

 

 

.

OFFSITE LOCATIONS

£ YES                   £ NO

Name of Offsite Location:

Type of Establishment:

Street Address:

Telephone Number:

City:

Number of Beds:

           Services Provided:

 

.

STAFFING

Indicate number of full time (FT) and part time (PT) employees. Attach additional pages if necessary.

 

 

FT

PT

1.

Board Membership (if applicable)

 

 

2.

Management

 

 

3.

Medical/Surgical Services

a.

Consultants

 

 

b.

Medical Officers

 

 

c.

House Officers

 

 

4.

Nursing

 

 

5.

Post Graduate Students/ Residents

 

 

6.

Support Services

 

 

7.

Allied Health

a.

LHV

 

 

b.

Technicians

 

 

c.

Midwives

 

 

d.

Physiotherapy Assistants

 

 

e.

Health aide

 

 

f.

Receptionist

 

 

8.

Pharmacy

 

 

9.

Therapists

a.

Physiotherapist

 

 

b.

Occupational therapist

 

 

c.

Speech therapist

 

 

10.

Volunteers

 

 

11.

Others

 

 

TOTAL Part Time

TOTAL Full Time

.

BUILDING PLANS & EQUIPMENTS

.

Building Plans

Do you have building plans?     £ Yes Complete            £ Yes but Incomplete            £ No

Are building alterations and remodeling proposed in the next 5 years?             £ Yes   £ No

Number of floors:

Residential Accommodation:    

Number of Generators:    

Parking:                            

Number of Chillers:      

 

 

.

List of Electro-Medical Equipment

 

.

List of Machinery

 

 

.

MANAGEMENT

.

CHIEF EXECUTIVE OFFICER (CEO)/INCHARGE/CHIEF OPERATING OFFICER (COO)

Name:

Title:

£Male     £Female

Begin Date:____/_____/_____

Status:

£ Interim  £ Acting  £Permanent

Email:

Phone Landline:

Mobile:

Is the CEO/In charge/COO in charge of more than one facility?            £Yes         £No

If yes, Name of facility, address and city: _______________________________________________________

 

Professional and Educational Qualifications of the CEO/ IC/ COO

 

 

.

PERSON INCHARGE IN ASBSENCE OF CEO / COO (SUBSTITUTE ADMINISTRATOR)

Name:

Title:

Contact Details:

Telephone:

Fax:

Professional and Educational Qualifications

 

 

.

MEDICAL DIRECTOR/MEDICAL SUPERINTENDENT (if different to A. above)

Name:

£ Male              £ Female

Begin Date ____/____/____

Title:

Status:     £ Interim   £ Acting    £ Permanent

Email:

Landline/ Fax:

Mobile:

Is the Medical Director in charge of more than one facility?         £Yes    £ No

 

Name Of Facility, Address and City:

 

 

Professional and Educational Qualifications

 

 

.

NURSE ADMINISTRATOR (DIRECTOR OF NURSING)

Name:

Begin Date: _____/_____/______

Email:

Landline:

Cell:

Professional and Educational Qualifications

.

PHARMACY INCHARGE

Name:

Begin Date: _____/_____/______

Email:

Landline:

Cell:

Professional and Educational Qualifications

.

LABORATORY INCHARGE

Name:

Begin Date: _____/_____/_______

Email:

Landline:

Cell:

Professional and Educational Qualifications

 

IV. OWNERSHIP

.

APPLICANT (OWNER)

Identify person(s) or business entity having the authority to direct the management or policies of the facility.

Name:

Street Address:

Mailing Address if different from Street Address:

Town:

City

Punjab

Telephone Number

Fax Number:

Email Address:

Name of Contact Person:

Title of Contact Person:

Telephone Number:

Cell:

Holding (what the owner owns)        £ Operations        £ Building        £Land

 

.

CHANGE OF OWNERSHIP

List the previous owner’s name

Name – Previous Owner:

 

 

.

SUBSIDIARY / PARENT INFORMATION

Is the applicant a subsidiary company, either wholly or partially owned by another organization or business?

                                                   £ YES                                £ NO

If yes, provide the following information.

Legal Business name – Parent Company:

Doing Business As:

Type of Ownership:

Mailing Address:

City

Telephone:

Contact Person:

 

 

 

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 license and I may also be found liable to pay fine to the Commission.  

Signature

Name of Applicant:

 

Date Signed:

 

Designation:

 

 

Explanatory Notes

.

General Information

 

.

Healthcare Establishment Location

In the absence of an official establishment email address, please insert the email address of the Establishment CEO.

 

.

Explain the License No. Section

 

.

External Validation 

If the Healthcare Establishment has obtained certification/accreditation from any recognized entity such as ISO, kindly state with the date of award/certification.

 

.

Services Provided by the Healthcare Establishment

This section is divided into three thematic areas. Kindly check the relevant box(es) for your Healthcare Establishment in each of these categories.

 

.

Offsite Locations

This section pertains to offsite locations like collection centers, offsite labs, immunization centers, blood banks, practice locations etc. An offsite location is not located or occurring at the site of a particular activity. Add additional pages if necessary.

 

.

Staffing

For the purposes of fulfilling the requirements of the Punjab Healthcare Commission Act 2010, the Healthcare Establishment must maintain an updated database of all doctors, nurses, technicians and assistants and other medical support staff. Please attach additional sheet with the names, qualifications, PMDC/Nursing Council registration numbers, email addresses and contact numbers of all medical staff.

 

 

.

Building Plans

 

Residential Accommodation pertains to the staff and doctors residing either on the premises of the healthcare establishment or a facility in arrangement with the healthcare establishment.

 

.

Ownership

 

Provide details of the owner and Head of Management of Healthcare Establishment. An owner for the purposes of the licensing form shall be a person that possesses the exclusive right to hold, use, benefit-from, enjoy, convey, transfer, and otherwise dispose of an asset or property or an executive who has the principleresponsibility for a process, program, or project.

Appendix A: Information of Full Time Staff

 

NAME

DESIGNATION

REGISTRATIONNUMBER

CONTACT INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Appendix B: Information of Part Time Staff

 

NAME

DESIGNATION

REGISTRATIONNUMBER

CONTACT INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Appendix CList of Electro-Medical Equipment

 

Sr. No.

Name of Equipment

Type

Model

Functional

Non-Functional

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


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About Me

Dr. Muhammad Iqbal is a board certified Homeopathic Skin and Beauty Specialist

Working Hours

Morning: 9.00 am - 2.00 pmEvening: 6.00 pm - 10.00 pm
Subscribe to My Newsletter


About Me

Dr. Muhammad Iqbal is a board certified Homeopathic Skin and Beauty Specialist

Working Hours

Morning: 9.00 am - 2.00 pmEvening: 6.00 pm - 10.00 pm