Private Hospitals Registration Form

1. PERSONAL DETAILS FOR THE PERSON IN-CHARGE

Tick the appropriate box.
1.3 Registration with Health Professions Council:
1.3.1 Registered as:
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8. STAFF COVERAGE

(A)PRACTITIONER(S) IN CHARGE


(B)LOCUM PRACTITIONERS


9. FEES
Tariff of Fees:
Will you be adhering to the tariff of fees agreed between service provider groups and AHFoZ as presented in the TPHAU or to the AHFoZ Scale of Awards applicable to your field of practice?


Payment/Claiming Procedure:
Tariff of Fees:
Which payment/claiming procedure will you be adopting?

10. BANKING DETAILS

I/We declare the Banking Details below are correct and authorize that they be used by the medical schemes and their administrators for reimbursement of claims




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    12. DECLARATION

    I/We, the undersigned, hereby declare that the information contained on the application form is correct and duly authorise the Association of Healthcare Funders of Zimbabwe (AHFoZ) to disseminate relevant information to its member societies.

    I/We undertake to advise AHFoZ of any changes to my/our practice profile in the event that such changes may occur. I/We further declare that I/We will abide by the rules governing the Provider Numbers.

    I/We acknowledge that any activities associated with fraud, waste and abuse will attract disciplinary measures as set out in the rules governing Provider Payee Numbers.

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