Khyber Pakhtunkhwa

KHYBER PAKHTUNKHWA HEALTH CARE COMMISSION

Bungalow No. 25-D, Circular Road, University Town Peshawar. www.hcc.gkp.pk

REGISTRATION/ RENEWAL OF CLINICS/ LABS/ X-RAY/ ULTRA SOUND/ CT SCAN/ MRI/ PHYSIOTHERAPY/ BLOOD BANK / THALASSEMIA CENTER. Fresh Registration: ______Renewal of Registration: ______Medical/ Dental Clinic: _____ 1. In case of renewal previous Reg. No. ______Valid up to: ______2. Any change in the facilities or staff , address etc. from previous year registration: ______3. Name and father name of Doctor (GP/ Specialist): ______4. Gender of Doctor: ______5. CNIC No of Doctor: ______6. Email ID of the Doctor: ______7. Contact No. of the Doctor: ______8. Postal Address of the residence of the doctor:______9. In Case of Government Job of the doctor ,details of designation and current place of posting: ______10. Professional Qualification/ Specialization details of the Doctor: ______11. PMDC Registration No: ______Valid Upto: ______12. Name of Health Care Facility: ______13. Postal Address of Health Care Facility: ______Tehsil: ______Distt.: ______14. Telephone Contacts No’s of the Health Care Facility: ______15. Name of Associated Medical Staff and their Professional Qualification (If any): ______16. Details of Services provided in the Health Facility: (i.e. X-Ray, Dialysis, Lab, OPD, Ultrasound, ECG, Echo etc.) (i).______(ii).______(iii).______(iv).______(v).______(vi).______(vii).______(viii).______17. Name of Incharge/ Owner: (If any) ______18. CNIC No of Incharge/ Owner: ______19. Postal Address of the residence of the Incharge/ Owner:______KHYBER PAKHTUNKHWA HEALTH CARE COMMISSION

NOTE: REGISTRATION FEE SHOULD BE DEPOSITED IN THE FOLLOWING BANK FEE CAN BE DEPOSITED ONLINE FROM ANY ALLIED BANK

Name of Bank: ALLIED BANK OF PAKISTAN PVT LTD Branch Code: 0936 (Army Stadium Peshawar) Account No: 1585-2

Fee Deposited Amount (in figures) ______(Amount in words)______Bank Receipt No: ______date: ______Name of the depositor (as per bank receipt): ______Name of the ABL bank branch where fee deposited: ______AFFIRMATION The information provided is correct to the best of my knowledge and belief, I accept full responsibility for health care facility and shall ensure that all instructions issued by the Khyber Pakhtunkhwa health regulatory authority from time to time regarding health institutions shall be complied and proper documentation shall be maintained. I also undertake that in case of any lapse in compliance, I shall be liable to penalization under the Khyber Pakhtunkhwa medical health institutions and regulation of health-care services ordinance 2002 and rules and regulations made thereof.

Dated Signature of Doctor applicant: ______FOR OFFICE USE ONLY Token No.: ______Issue Date: ______Issued By: ______I - FOR ACCOUNT SECTION OF HRA (i) Verification of the bank receipt from bank statement:______(ii) Name &dated Sign of the account section clerk:______II - Applied Fresh or renewal of Registration: ______Checked by: ______III - FOR REGISTRATION SECTION Amount due (in figures) ______Amount due (in words) ______Amount Deposited (in Figures) ______Amount Deposited (in words) ______Difference in amount (Arrears):______Details of difference in amount (Arrears): ______Verification from PMDC website: ______Registration Clerk Remarks, Name & signature: ______ATTESTED COPIES OF THE FOLLOWING REQUIRED DOCUMENTS SHOULD BE ATTACHED TO THIS APPLICATION FORM 1. Professional Certificates 2. Two Passport size photographs 3. CNIC (photocopy) of doctor 4. Sketch of the Health facility 5. Health facility Pad copy (with the printed PMDC No., prescription pad bearing names of more than one doctor is not acceptable) 6. Original Bank receipt 7. Rate list of the services (OPD Fee, X-Ray Fee etc.) 8. PNRA Certificates for CT Scan X-ray and Angiography units 9. Experience Certificate in case of Labs and Radiology services KHYBER PAKHTUNKHWA HEALTH CARE COMMISSION

NOTE: ATTACH ADDITIONAL SHEET FOR DETAILS IF REQUIRED. HRA Fee Details

1 Hospital, Nursing Homes and Maternity Homes Per Bed 150 Per Bed 75 Per Room 500 Per Room 250 2 Operation Theatre Rs.10,000 Rs.5,000 3 Specialist Clinic Rs.3,000 Rs.2,000 4 General Practitioner Rs.1,000 Rs.500 5 Clinical Laboratory Category D (Routine Test) Rs.1,000 Rs.1,000 6 Clinical Laboratory Category C (Blood sugar & Routine Rs.2,000 Rs.2,000 Test) 7 Clinical Laboratory Category-B (Immunology, Chemistry & Rs.4,000 Rs.4,000 Hematology) 8 Clinical Laboratory Category-A Immunology, Rs.5,000 Rs.5,000 Chemistry, Hematology, Histopathology & Microbiology) 9 X-Ray Clinic Rs.5,000 Rs.5,000 10 Ultra sound Clinic Rs.5,000 Rs.5,000 11 C T Scan and MRI Rs.10,000 Rs.10,000 12 Dental Clinic Rs.1,000 Rs.1,000 13 Dental Clinic (Specialist) Rs.5,000 Rs.3,000 14 ECG Clinic Rs.1,000 Rs.1,000 15 ETT Clinic Rs.4,000 Rs.2,000 16 Echocardiography Clinic Rs.5,000 Rs.4,000 17 Physiotherapy Clinic Rs.5,000 Rs.5,000 18 Homeopathic Clinic Rs.1,000 Rs.500 19 Homeopathic Clinic (Specialist) Rs.3,000 Rs.2,000 20 Tibb (Hakim) Clinic Rs.1,000 Rs.500 21 Tibb (Hakim) Clinic (Specialist) Rs.3,000 Rs.3,000 22 Audiometric Clinic Rs.1,000 Rs.1,000 23 Thalasemic centers Rs.1,000 Rs.1,000 24 Labour Room Rs.5,000 Rs.5,000 25 Lithrotripsy Clinic Rs.5,000 Rs.5,000