Laboratory Profile Registration Form

Please follow the instructions carefully since the submission of incomplete applications will delay the processing and issuance of the registration.

If your laboratory already has an AHFoZ Payee number, please indicate here:

2. GENERAL INFORMATION:

Laboratory Name

HPA Number:

City Council Business Number:

Laboratory Address (Physical Location of Laboratory):

Province:

District:

City:

Postal Address):

City:

Telephone Number:

FAX Number:

Practitioner In Charge Name :

Laboratory E-mail Address:

Basic Qualification:

Spec/Post Basic Qualification:

Telephone Number:

E-mail Address:

Indicate the Additional Support Team:

Practitioner In Charge Name :

Basic Qualification:

Spec/Post Basic Qualification:

Telephone Number:

E-mail Address:

3. LABORATORY TYPE:

Indicate

5. AFFILIATION:

If your laboratory is affiliated with a laboratory holding an AHFoZ Payee Number, provide the name, address, and AHFoZ Payee Number. Do not provide the name and AHFoZ Payee Number of your reference laboratory.

AHFoZ Number:

Name of Laboratory:

Address:

Province:

District:

City:

5.1 AFFILIATION:

If your laboratory is affiliated with a laboratory holding an AHFoZ Payee Number, provide the name, address, and AHFoZ Payee Number. Do not provide the name and AHFoZ Payee Number of your reference laboratory.

AHFoZ Number:

Name of Laboratory:

Address:

Province:

District:

City:

7. TEST PROCEDURES REQUESTED:

9. PROVIDER-PERFORMED MICROSCOPY (PPM) PROCEDURES REQUESTED:

Other

5.1Equipment Used:

List Below the type of Equipment /Machine used and Test done by the indicated Equipment/Machine

Name of Machine

Make and Serial Number:

Test Conducted:

Commissioning Done By :

Date

Maintenance Schedule:

5.1Equipment Used:

List Below the type of Equipment /Machine used and Test done by the indicated Equipment/Machine

Name of Machine

Make and Serial Number:

Test Conducted:

Commissioning Done By :

Date

Maintenance Schedule:

5.1Equipment Used:

List Below the type of Equipment /Machine used and Test done by the indicated Equipment/Machine

Name of Machine

Make and Serial Number:

Test Conducted:

Commissioning Done By :

Date

Maintenance Schedule:

5.1Equipment Used:

List Below the type of Equipment /Machine used and Test done by the indicated Equipment/Machine

Name of Machine

Date

Maintenance Schedule

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

Practice Name

Name of Bank

Name of Branch

Account Name

Branch Code

Account No.

Type of Account

Provider's Name

Please upload your supporting documents here.

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 128 MB, Max. files: 15.

11. CERTIFICATION.
I understand that by signing this application form, I agree to any Accreditation visit made by the to verify or confirm the information provided herein or adjunctive to this application, and any accreditation in connection with my laboratory registration, a complaint or incident report made known to the Department. Registration under this subdivision may be denied, limited, suspended, revoked or annulled by the Department upon a determination that a laboratory services registrant: (i) failed to comply with the requirements of this subdivision; (ii) provided services that constitute an unwarranted risk to human health; (iii) intentionally provided any false or misleading information to the Department relating to registration or performing laboratory services; or (iv) has demonstrated incompetence or shown consistent errors in the performance of examinations or procedures. If additional information is requested, I will provide it. Further, I understand that, should this application or my status be investigated at any time, I agree to cooperate in such an verification.

Laboratory test registrants shall: (i) provide only the tests and services listed on the registration issued by the Department hereunder; (ii) advise the Department of any change in the registrant's name, ownership, location or qualified health care professional or laboratory director designated to supervise testing within thirty days of such change; (iii) provide the department with immediate access to all facilities, equipment, records, and personnel as required by the Department to determine compliance with this subdivision; (iv) comply with all public health law and federal requirements for reporting reportable diseases and conditions to the same extent and in the same manner as a clinical laboratory; and (vi) designate a qualified health care professional or qualified individual holding a certificate of qualification pursuant to section five hundred seventy-three of this title, who shall be jointly and severally responsible for the testing performed.

By signing this application, I hereby attest that the information I have given as a basis for obtaining a Laboratory Registration is true and correct, that I have read the relevant rules and regulations, and that I accept responsibility for the tests indicated in Section(s Provider-Performed Microscopy (PPM) Procedures Requested of this application.

2. GENERAL INFORMATION:

3. LABORATORY TYPE:

5. AFFILIATION:

5.1 AFFILIATION:

7. TEST PROCEDURES REQUESTED:

9. PROVIDER-PERFORMED MICROSCOPY (PPM) PROCEDURES REQUESTED:

5.1Equipment Used:

5.1Equipment Used:

5.1Equipment Used:

5.1Equipment Used:

10. BANKING DETAILS

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