Application Form of a Medical Institution for Practicing Registration

Prepared by Hainan Provincial Health Commission

Schedule 5-1

Instructions

1. This form is exclusively for medical institutions applying for a Practicing License for a Medical Institution from the registration authority.

2. Medical institution code   Fill in according to the relevant provisions of the Administration Measures for the Code and Database of Health Entities (Interim) (W.T.F. [1991] No. 6) and supplemental provisions.

3. Schedule 5-2 Affiliation   Fill in the selected item number in the parentheses provided; only one can be filled in.

4. Schedule 5-2 Ownership form   Fill in the selected item number in the parentheses provided; only one can be filled in.

5. Schedule 5-2 Service recipient   Fill in as per the requirements in 4.

6. Schedule 5-2 Legal representative   For a medical institution with legal personality, fill in the name of the legal representative; if the medical institution does not have legal personality, fill in the name of the legal representative of the competent entity that has legal personality.

7. Schedule 5-3 Mark with a “∨” in the □ before the diagnosis and treatment item codes.

8. Schedule 5-3 Medical institutions that set up secondary disciplines (specialty groups) under any primary discipline must fill in the secondary disciplines; medical institutions that do not set up secondary disciplines (specialty groups) only need to fill in the primary disciplines. If a discipline only provides outpatient services, it shall be noted in the remarks column as “Outpatient”.

9. Schedule 5-3 Institutions that only provide specialized disease diagnosis and treatment shall fill in the corresponding discipline of specialized disease diagnosis and treatment, and indicate the name of the specialized disease in the remarks column. For example, a cervical spondylosis specialty diagnosis and treatment institution shall fill in “Orthopedics” and note “Cervical Spondylosis Specialty”.

10. Schedule 5-4 Fill in the corresponding number of people in each item.

11. Schedule 5-4 Managers   It refers to the leaders of the medical institution and management personnel at all levels of the functional departments, excluding financial personnel.

12. Schedule 5-4 Rehabilitation Therapists   It refers to personnel engaged in physical therapy, occupational therapy, speech therapy, physical modality therapy and traditional rehabilitation therapy.

13. Schedule 5-5 General equipment   Fill in each item according to the medical equipment standards in the Basic Standards for Medical Institutions.

14. This application form is made in triplicate and can be downloaded from the websites of Hainan Provincial Government Service Center or Hainan Provincial Health Commission. Websites: http://www.hizw.gov.cn; http://www.wst.hainan.gov.cn