PRACTICE NUMBER APPLICATION

Transcription

1 No 13. Feld Street Windhoek, Namibia P. O. Box Klein Windhoek Tel: /2 Fax: Mail: Website: PRACTICE NUMBER APPLICATION Date of application: Name in which practice number will be allocated (Prof., Dr., Sr., Mr., Mrs., Ms., Name of Facility, etc.):... Trading Name:... Scope of Practice: KINDLY COMPLETE THIS FORM IN PEN, WITH A LEGIBLE PRINT. ALL PHOTOCOPIES OF DOCUMENTS MUST BE CERTIFIED. FAXED APPLICATIONS ARE NOT ACCEPTABLE. APPLICATIONS WILL NOT BE PROCESSED UNLESS ALL REQUIRED DOCUMENTS ARE ATTACHED. NO CASH PAYMENT WILL BE ACCEPTED. ONLY CROSSED CHEQUES ISSUED TO NAMAF OR POSTAL ORDERS. PRACTITIONERS WORKING AS EMPLOYEES OR LOCUMS DO NOT REQUIRE A PRACTICE NUMBER.

2 The following information is required for the allocation of a NAMAF practice number: A. All Applicants: (General Practitioner, Specialist, Anesthetist, Nurse, Psychologist, Physiotherapist, Optometrist, Dentist, etc). (Please note that in partnership practices, all the partners must each apply separately for a personal practice number and then a joint application must be submitted for the partnership). 1. Certified copy of current year s registration with the relevant Interim Health Profession s Council in Namibia. (In the case of a group practice, all practitioners certificates must be attached) 2. Certified copy of Namibian Identity Document / Namibian Passport / Namibian Work Permit / Namibian Permanent Resident Permit. 3. Certified copy of Marriage Certificate. (If married). 4. Certified copy of current year s Health Registration Certificate, as issued by the Ministry of Health and Social Services. (Please note, that as a legislative control measure ALL medical practitioners have to register for a License or Health Registration Certificate with the Ministry of Health and Social Services, irrespective of whether or not the practitioner has rooms that need to be inspected (e.g. an anesthetist, private nurse, etc). Queries in this regard must be directed to Mr. Kisting at Tel: / Ms. Mercia at Tel: at the Ministry of Health & Social Services. B. Practitioners for which no Namibian Professional Council exists: Certified copy of current year s registration certificate, as issued by the Health Professions Council of Namibia (Mr. E. Weyulu Tel: (061) ). C. Nurses at Clinics, Hospices, etc: Certified copy of current year s Health Registration Certificate, certified copy of current year s Namibian Interim Nursing Council Registration Certificate, certified copy of Namibian ID/Passport, Work Permit, Permanent Residence and Marriage Certificate. D. Private Nurses / Nursing Institutions who wish to acquire, possess, use and supply certain medicines to patients, (i.e. diagnose and prescribe): Copy of current 22A(12) permit, as issued by the Ministry of Health & Social Services in terms of the Medicines and Related Substances Act, 1965 (Act No. 101 of 1965) Note: Without this Permit, no medicines may be prescribed by a Nurse without the supervision of an attending doctor. The doctor s script must be attached to the claim for medicine to verify his/her attendance). E. Pharmacists: Certified copy of the current year registration/practicing certificate from the Pharmacy Council of Namibia for both the Pharmacist and the owner/manager of the Pharmacy. Certified copy of Namibian ID/Passport, Work Permit, Permanent Residence Permit, and certified copy of Marriage Certificate. 2

3 F. STATE- EMPLOYED PRACTITIONERS: NAMAF does not allocate practice numbers to State employed practitioners unless the following is provided: 1. Certified copy of a letter from the Permanent Secretary of the Ministry of Health and Social Services, granting permission that limited private practice may be undertaken. OR 2. If the practitioner has resigned from the State, a copy of the letter from the Ministry of Health accepting the resignation. G. Hospital & Health Facilities & Rehabilitation Centers, etc: 1. Certified copy of the current year s Health Registration Certificate in terms of Section 23 of the Hospitals & Health Facilities Act, 1994 (Act 36 of 1994), as allocated by the Ministry of Health and Social Services. 2. Should the hospital have an X-ray, Pathology and Pharmacy, a separate practice number application must be submitted for each of these departments, (i.e. these services cannot be claimed under the Hospital Practice Number). The practicing practitioner in these departments must provide their Namibian professional Registration Certificates, License/Registration Certificate as allocated by MOHSS, Namibian ID/Passport or Work Permit, and marriage certificate. The Pharmacy must register separately, (see criteria for a Pharmacy application under Point E). 3. Clinics/Rehab Centres/Frailcare Centres/Hospices must provide a certified copy of the Namibian Professional Registration Certificate of all nurses, social workers, clinical psychologists that are employed at the facility. 4. Certified copy of the Namibian Incorporated Certificate from the Registrar of Companies. (Where applicable for hospitals, clinics, hospices, etc). 5. Emergency / Ambulance Services must provide a (a) certified copy of all the Paramedics Namibian Registration Certificates, ID s or Work Permits, marriage certificates and (b) certified copy of the Health Registration Certificate, as provided by the Ministry of Health and Social Services. 3

4 1. POSTAL ADDRESS OF PRACTICE: (This is the address that all correspondence and/or invoices from NAMAF and the Funds will be posted to. Thus you should ensure that it is the correct address and furthermore that you keep NAMAF informed of any change in address. If you fail to do this, then you will not receive NAMAF s Annual Fee Invoices for the renewal of your number annually, which means that your number could be deleted from the database system). POSTAL ADDRESS: SUBURB: TOWN: COUNTRY: POSTAL CODE: 2. PHYSICAL ADDRESS OF PRACTICE: NUMBER OF OFFICE/ HOUSE/ FLAT, ETC: STREET NAME: SUBURB: TOWN: COUNTRY: 3. STARTING DATE OF PRACTICE: 4. IF JOINING AN EXISTING PARTNERSHIP PRACTICE, PROVIDE THE PARTNERSHIP PRACTICES NUMBER: 4

5 5. IS THIS A SOLUS OR PARTNERSHIP PRACTICE? SOLUS PARTNERSHIP NOTE FOR PARTNERSHIP PRACTICE: (a) For a Partnership Practice all partners professional Registration Certificates, ID s, etc, must be attached; And; (b) If these partners already possess a personal practice number, such number must be indicated, per partner on this application; And; (c) (d) If a partner does not possess a personal practice number, he/she must apply separately to the Partnership Application, to get such a personal number. The Facility s Health Certificate can be in the Partnership name, but a certificate must be allocated for each partner, with a different certificate number. Queries in this regard must be directed to Mr. Kisting at MOHSS Tel: / ) PARTNERS EXISTING PERSONAL PRACTICE NUMBERS:

6 NOTE: A practitioner s Personal Practice Number MAY NOT be used for partnership claims NOR may a Partnership Practice Number be used by a doctor in a solus practice. 6. IF YOU HAVE AN EXISTING PRACTICE NUMBER PLEASE PROVIDE THIS NUMBER. If you had a practice number previously whether it is a BHF or NAMAF number, this must be indicated. NAMIBIAN PRACTICE NUMBER: SOUTH AFRICAN PRACTICE NUMBER: DATE OF CLOSURE OF PRACTICE: (If you have left a partnership practice kindly indicate the partnership s practice number. 7. PRACTICE DETAILS: (This applies to the new practice). AREA CODE: TELEPHONE NO: FAX NO: CELL PHONE NO: EMERGENCY TEL. NO: ADDRESS: 6

7 8. DENTISTS ONLY: Does your practice have a Dental Laboratory attached to it? If yes, please attach the Dental Technologist(s) Professional Registration Certificate(s), as issued by the Interim allied Health Profession s Council and a Health registration Certificate issued by the Ministry of Health and Social Services. YES NO 9. HOSPITALS ONLY: Do you have an ICU? Yes/No. How may beds in ICU?..... Do you have a Theatre Yes/No. How many beds in Theatre?..... Do you have a High Care? Yes/No. How many beds in High Care?. Ratio of number of ward beds to number of theatres:. Ratio of nursing staff to ward beds and ICU:. 10. PROFESSIONAL BOARD REGISTRATION NUMBERS FOR YOUR RELEVANT SCOPE OF PRACTICE: (A practice number may only be allocated for the scope of practice that you are registered in with your professional Namibia Board. A certified copy of the relevant certificate MUST be attached tot his application) NAMIBIAN BOARD REGISTRATION NUMBER (S) NOTE: (Dr s in partnership applying for a Partnership Practice Number must list all the partners Board Registration numbers and the doctor s names

8 11. ARE YOU OPERATING A PRACTICE IN SOUTH AFRICA IN ADDITION TO YOUR NAMIBIAN PRACTICE? YES NO 12. BANK DETAILS (This is to facilitate speedy payment by Funds directly into your bank account. Many of the Funds conduct electronic cheque payments instead of issuing manual cheques through the post). ACC NAME: ACCOUNT NO: BANK: BRANCH NAME: BRANCH CODE: TYPE OF ACC: PLEASE ATTACH A CANCELLED CHEQUE FOR BANK DETAILS EDI USER: YES NO EDI COMPANY: a. WOULD YOU PREFER THAT MEDICAL AID FUNDS REIMBURSE YOU BY MAKING A DIRECT PAYMENT INTO YOUR BANK ACCOUNT? (If yes, then point 11 must be completed). YES NO 8

9 13. REGISTRATION FEE: An immediate registration fee of N$. is payable to NAMAF. This is a once off- fee which is payable upon registration. (For security reasons only a crossed cheque, direct bank deposits/eft made out to NAMAF, is acceptable. No cash payments will be accepted) Account Name: NAMAF Bank: FNB Namibia (Commercial Branch) Account Number: Branch Code: (Please send proof of payment with your application form) 14. ANNUAL REGISTRATION FEE: Please note that, in order to maintain your practice number on the PCNS system, an Annual Renewal Fee, payable to NAMAF, shall be charged on an annual basis. An invoice shall be posted to you at the beginning of each year. Payment must be made by the deadline indicated in the renewal notice. Failing this the practice number will be deleted from the PCNS system. Thus, it is VERY important that you keep NAMAF informed of your correct postal address, (i.e. if you have a change in address you must inform us in writing of this change can be faxed). Payment of the annual renewal fee must be made by crossed cheque or postal order issued to NAMAF. Cash payments will not be accepted. Practice details of all healthcare providers in Namibia are registered on a unique database, known as the Practice Code Numbering System (PCNS), which has powerful applications, and to which Medical Aid Funds have access in order to process service providers claims. The practice number, allocated to all registered healthcare providers, is the essential billing code that triggers the process of reimbursement of a claim to either a Medical Aid Fund or service provider. This is in accordance with the requirement of the Namibian Medical Aid Funds Act No. 23 of 1995, wherein it is stated that a Medical Aid Fund may only reimburse a member, or a provider of healthcare services, against a valid practice number. The PCNS Advisory Forum, made up of representatives from the statutory councils, professional associations, Medical Aid Funds and Administrators was set up with the express purpose of information exchange in order to ensure that the integrity and accuracy of the system is maintained, and to ensure good governance in respect of the financial management and future developments of the system. It has been recognized by the PCNS Forum that healthcare providers and Medical Aid Funds administer the system on an independent, self-funding and non-for profit basis, since these are the two parties who enjoy the benefits of the system. Following considerable debate, it was further agreed that there was an equal benefit derived from the system by the Medical Aid Fund members and individual PCNS users in the claiming and reimbursement of services rendered. Consequently, the principle of funding the system should be equitable to all concerned. This would entail that the PCNS subscribers (the medical aid funds and service providers) equally share the financial risk. 9

10 15. DECLARATION: I confirm that I understand this application and that the information given on this application is true and correct: NAME :.. SIGNATURE :.. SCOPE OF PRACTICE :.. DATE :.. VERY IMPORTANT NOTE: Practice Numbers are not transferable from one healthcare provider to another. Should a healthcare provider or health facility sell the practice to another party, the seller must inform NAMAF in writing of this sale, and the purchaser must apply to NAMAF for a new, individual practice number, (i.e. the selling practitioner s practice number may not be used by the new practitioner this would be viewed as fraudulent practice by NAMAF and the Medical Aid Funds). ANNUAL FEE RENEWALS The following certified documents needs to be submitted with your annual practice number renewals Proof of registration with relevant Council Dispensing license (if applicable) Current Health certificate OR PROOF OF RENEWAL 10