Mu 06

(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 giy chng nhn ng k kinh doanh hoc giy
chng nhn u t.
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 ca tng c nhn lm vic chuyn mn y t ti c s khm bnh,
cha bnh nhng khng thuc din phi cp chng ch hnh ngh (nu c):
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 k thut chuyn mn.
7. Hp ng:
- Hp ng x l cht thi y t (i c s khng xy dng h thng x l
cht thi y t).

- Hp ng vi c s c phng tin cp cu (i vi Phng khm a

khoa, Nh h sinh khng trang b c phng tin cp cu)

- Hp ng vi cng ty dch v hng khng

8. Giy chng nhn an ton bc x (i vi c s c lp t my X-quang).

Knh ngh S Y t thm nh v cp giy php hot ng./.
NGI LM N
(K v ghi r h, tn)
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.