Specialist Registration Form

1. PERSONAL DETAILS

Title
Initials
First Name
Surname
Basic Registered as
Registration No.
Spec/Post Basic Registered as
Registration No.
Practicing Certificate No.
MM slash DD slash YYYY
Effective Date
MM slash DD slash YYYY
Expiry Date
Previous AHFoZ Provider Payee No.
Health Professions Authority Premises No.
MM slash DD slash YYYY
Effective Date
MM slash DD slash YYYY
Expiry Date

2. CONTACT DETAILS

3. 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.
Drop files here or
Accepted file types: jpg, gif, png, pdf, Max. file size: 128 MB, Max. files: 15.


    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.

    MM slash DD slash YYYY