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 Complex, 38-Abbot Road, Lahore

•

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

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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____________________________________

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

Medical

Surgical

Intensive Care

Neonatal

Operating Room

Emergency Room

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.

Board Membership (if applicable)

Management

Medical/Surgical Services

Consultants

Medical Officers

House Officers

Nursing

Post Graduate Students/ Residents

Support Services

Allied Health

LHV

Technicians

Midwives

Physiotherapy Assistants

Health aide

Receptionist

Pharmacy

Therapists

Physiotherapist

Occupational therapist

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 C: List of Electro-Medical Equipment

Sr. No.	Name of Equipment	Type	Model	Functional	Non-Functional

M	T	W	T	F	S	S
					1	2
3	4	5	6	7	8	9
10	11	12	13	14	15	16
17	18	19	20	21	22	23
24	25	26	27	28	29	30
31

Application 2

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