APPLICATION FOR LICENSE
FOR HEALTHCARE ESTABLISHMENTS (HCEs)
Category III - HCEs having no indoor facilities
Healthcare Establishments are required to complete this form as per the requirements of the provisions of
Punjab Healthcare Commission Act 2010.
Required Documents;
o Copy of CNIC
o Copy of Degree/ Diploma
o Copy of Updated Registration with relevant Council (PMDC/ PNC/ NCH/ NCT)
o HCE Staff list
o HCE Equipment and Machinery List
Incomplete forms will not be entertained.
Provision of incorrect information/documents will result in rejection of the Application.
Return the completed form to:
Directorate of Licensing & Accreditation,
Punjab Healthcare Commission
Office # 1 & 2, 4th Floor Shaheen Complex, 38-Abbot Road, Lahore
Questions regarding completion of this application may be directed to: Ph. 042 36376371 - 8
For further information, please visit our web site : www.phc.org.pk
I.
GENERAL INFORMATION
A. HEALTHCARE SERVICE PROVIDER
Name:
Designation: _________________________
Status:
Qualification:
Owner
Manager
In-charge
CNIC Number:
Registration No. PMDC/ PNC/ NCH/ NCT:
Mailing Address:
Town/ City:
Tehsil:
District:
Punjab
Telephone:
Landline____________
Mobile) ______________________
Fax:
Email:
A. HEALTHCARE ESTABLISHMENT (HCE)
Name:
Date of establishment at present
Location:
(Day/Month/Year)
Previous Name (If any):
Mailing Address:
Town/ City:
Tehsil:
District:
Telephone:
Landline__________
Fax:
Punjab
Email:
Mobile) ____________________
B. TYPE OF ORGANISATION
Type of Ownership (please check the appropriate box)
Government
District Government
Provincial Government1
Federal Government
Autonomous Institution
Others
Sole Proprietary
Partnership
Corporation
Trust
Voluntary Non- Profit
Association
Limited Liability Company
(Private)
Limited Liability Company
(Public)
CMH/ Cantonment
Hospital
C. TYPE OF HEALTHCARE ESTABLISHMENT (please check the relevant box)
Single Specialty (please specify): _____________________________________________________
Multiple Specialty
Others
GP Clinic/ Homeopath/ Hakim/ Lab/ Collection Center/ Radiological or Imaging/Maternity
or Nursing
homes/ Dental clinic/ Cosmetic Surgery/ Laser Clinic/ Physiotherapists/
Acupuncturists/ If any other please specify: ______________________
D. SERVICES PROVIDED BY THE HEALTHCARE ESTABLISHMENT
Mention the Healthcare Services Provided;
1.
2.
3.
4.
5.
II.
MANAGEMENT
A. HCE MANAGER/ INCHARGE
Name:
Title:
Male
Email:
Female
Begin Date:____/_____/_____
Phone Landline:
Is the CEO/In charge/COO in charge of more than one facility?
Status:
Interim Acting
Permanent
Mobile:
Yes
No
If yes, Name of facility, address and city: _______________________________________________________
Professional and Educational Qualifications of the HCE Manager/ Incharge
B. PHARMACY INCHARGE (If Applicable)
Name:
Begin Date: _____/_____/______
Email:
Landline:
Cell:
Professional and Educational Qualifications
C. LABORATORY INCHARGE (If Applicable)
Name:
Email:
Landline:
Begin Date: _____/_____/_______
Cell:
Provincial Government includes Social Security, Aquaf department & Family planning department
Professional and Educational Qualifications
III. OWNERSHIP
A. APPLICANT (OWNER)
Identify person(s) or business entity having the authority to direct the management or policies
of the facility.
Name:
Street Address:
Mailing Address if different from Street Address:
Town:
City
Punjab
Telephone Number
Fax Number:
Email Address:
Name of Contact Person2:
Title of Contact Person:
Telephone Number:
Cell:
Holding (what the owner owns)
Operations
Building
Land
B. CHANGE OF OWNERSHIP
List the previous owners name
Name Previous Owner:
DECLARATOIN
I, the undersigned, do hereby solemnly affirm and declare that the information provided
above is true and correct to the best of my knowledge and belief and that nothing has been
concealed therefrom. I also state that if any false or incorrect information is provided to the
Commission, it may result in rejection of my application for license and I may also be found
liable to pay fine to the Commission.
Signature
Name of Applicant:
Date Signed:
Designation:
Explanatory Notes
I. General Information
A. Healthcare Establishment Location
In the absence of an official establishment email address, please insert the email
address of the Establishment CEO.
B. Staffing
For the purposes of fulfilling the requirements of the Punjab Healthcare
Commission Act 2010, the Healthcare Establishment must maintain an updated
database of all doctors, nurses, technicians and assistants and other medical
support staff. Please attach additional sheet with the names, qualifications,
PMDC/Nursing Council registration numbers, email addresses and contact
numbers of all medical staff.
II.
Ownership
Provide details of the owner and Head of Management of Healthcare Establishment. An
owner for the purposes of the licensing form shall be a person that possesses the
exclusive right to hold, use, benefit-from, enjoy, convey, transfer, and otherwise dispose
of an asset or property or an executive who has the principle responsibility for
a process, program, or project.
Appendix A: Information of Full Time Staf
NAME
DESIGNATIO
N
REGISTRATIO
N NUMBER
CONTACT
INFORMAT
ION
Appendix B: Information of Part Time Staf
NAME
DESIGNATIO
N
REGISTRATION CONTACT
NUMBER
INFORMAT
ION
Appendix C: List of Electro-Medical Equipment
Sr.
No.
Name of
Equipmen
t
Type
Model
Functio
nal
NonFunctional
Functio
Non-
Appendix D: List of Machinery
Sr.
Name of
Type
Model
No.
Equipme
nt
nal
Functional
