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Mu 05

(Ban hnh km theo Quyt nh s 617/Q-UBND-HC


ngy 28 thng 6 nm 2013 ca Ch tch UBND tnh ng Thp)

CNG HO X HI CH NGHA VIT NAM


c lp T do Hnh phc

.............................. 1, ngy....... thng..... nm 20.....


N NGH
Cp giy php hot ng i vi c s khm bnh, cha bnh
Knh gi: S Y t tnh ng Thp.
Tn c s khm bnh, cha bnh:...........................................................................
a im: 2...........................................................................................
in thoi:.............................................. Email (nu c): .....................................
Thi gian lm vic hng ngy: ...........................................................................
nh km theo theo n ny gm cc giy t sau:
1. Bn sao c chng thc quyt nh thnh lp c s khm bnh, cha bnh;
2. Danh sch ng k hnh ngh khm bnh, cha bnh.
3. Bn sao chng ch hnh ngh ca tt c ngi hnh ngh 3.
4. H s nhn s ca ngi lm vic chuyn mn y t ti c s (din khng
phi cp chng ch hnh ngh).
4.1. Bn sao c chng thc vn bng chuyn mn.
4.2. Giy chng nhn sc kho.
4.3. S yu l lch.
5. Bng k khai c s vt cht, thit b y t.
6. Danh mc chuyn mn k thut.
7. Giy chng nhn an ton bc x (i vi c s c lp t my X-quang).
8. Hp ng x l cht thi y t (nu c s khng xy dng h thng x l
cht thi y t).
9. iu l t chc v hot ng bnh vin (i vi c s l bnh vin).
Knh ngh S Y t thm nh v cp giy php hot ng./.
GIM C
(K tn v ng du)

1. a danh.
2. a ch c th ca c s khm bnh, cha bnh.
3. Chng ch hnh ngh khng do S Y t ng Thp cp th np bn sao c chng thc.

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