Application Form of a Medical Institution for Verification

Prepared by Hainan Provincial Health Commission

Instructions

1. This form is exclusively for medical institutions applying to the registration authority for medical institution verification and shall be submitted in triplicate. It can be downloaded from the website of Hainan Provincial Health Commission.

Website: http://www.wst.hainan.gov.cn

2. Materials required to be submitted include:

(1) Application Form of a Medical Institution for Verification;

(2) A duplicate of the Practicing License for a Medical Institution;

(3) Annual work summaries;

(4) Changes in diagnosis and treatment items, number of sickbeds (dental chairs) and other practice registration items, as well as changes in health technicians, business departments and major medical equipment;

(5) Results of inspections and guidance from health administrative departments during the verification period, along with any corrective actions taken;

(6) Medical civil compensation (including medical accidents) and handling of any practicing violations by health technicians during the verification period; and

(7) Special medical technology projects conducted.

3. Medical institution code: Fill in according to the relevant provisions of the Health Institution (Organization) Categorization and Code (W.B.F. [2002] No. 117).

4. Legal representative: If the medical institution is a legal person entity, fill in the name of the legal representative; if the medical institution is not a legal person entity, fill in the name of the primary person in charge.

5. Table 2 Managers   It refers to the leaders of the medical institution and management personnel at all levels of the functional departments, excluding financial personnel.

6. Table 2 Rehabilitation Therapists   It refers to personnel engaged in physical therapy, occupational therapy, speech therapy, physical modality therapy and traditional rehabilitation therapy.

7. Table 4 Formula for calculating the average length of stay in hospital:

Total sickbed days occupied by discharged patients

Number of discharged patients

8. Table 4 Formula for calculating the average medical expense per outpatient visit (in RMB):

Total outpatient medical expenses last year (in RMB)

Total outpatient visits last year

Outpatient medical expenses include registration fees, medication costs, examination and treatment fees.

9. Table 4 Formula for calculating the average medical expense per discharged patient (in RMB):

Total inpatient medical expenses last year (in RMB)

Total number of discharged patients last year

Inpatient medical expenses include hospitalization fees, medication costs, surgery fees, examination and treatment fees.

10. Table 4 Formula for calculating the average daily medical expense per discharged patient (in RMB):

Average medical expense per discharged patient (in RMB)

Average length of stay in hospital