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    Application Form

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    Aglaia Ortile
    This document is a physician application and information sheet for PAHMOC. It collects personal and professional information from physicians applying for inclusion in PAHMOC's MOA, including name, contact details, medical license and certificate numbers, hospital affiliations, specialty, and schedule. The physician agrees to the terms of PAHMOC's MOA and understands their unified service agreement will terminate if their contract with an accredited society ends. Required documents like birth certificates, CVs, and data privacy consent forms must be attached.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Application Form

    Uploaded by

    Aglaia Ortile
    36 views1 page
    This document is a physician application and information sheet for PAHMOC. It collects personal and professional information from physicians applying for inclusion in PAHMOC's MOA, including name, contact details, medical license and certificate numbers, hospital affiliations, specialty, and schedule. The physician agrees to the terms of PAHMOC's MOA and understands their unified service agreement will terminate if their contract with an accredited society ends. Required documents like birth certificates, CVs, and data privacy consent forms must be attached.

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    This document is a physician application and information sheet for PAHMOC. It collects personal and professional information from physicians applying for inclusion in PAHMOC's MOA, including name, contact details, medical license and certificate numbers, hospital affiliations, specialty, and schedule. The physician agrees to the terms of PAHMOC's MOA and understands their unified service agreement will terminate if their contract with an accredited society ends. Required documents like birth certificates, CVs, and data privacy consent forms must be attached.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    36 views1 page

    Application Form

    Uploaded by

    Aglaia Ortile
    This document is a physician application and information sheet for PAHMOC. It collects personal and professional information from physicians applying for inclusion in PAHMOC's MOA, including name, contact details, medical license and certificate numbers, hospital affiliations, specialty, and schedule. The physician agrees to the terms of PAHMOC's MOA and understands their unified service agreement will terminate if their contract with an accredited society ends. Required documents like birth certificates, CVs, and data privacy consent forms must be attached.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 1

    PAHMOC

    PHYSICIAN APPLICATION AND INFORMATION SHEET

    I have read, understood and agreed to all provisions of the PAHMOC MOA covering the period ___________ and wish to apply for
    inclusion therein. If approved, I understand that the Unified Service Agreement (USA) that shall be issued to me by PAHMOC and
    will automatically terminate upon the termination of contract with the accredited society.
    A. PERSONAL DATA
    NAME: ___________________________ ___________________________ ___________________________
    First Name Middle Name Surname
    BIRTHDATE: ___________________________ GENDER _____________ STATUS _____________
    PREFERRED MAILING ADDRESS
    HOME __________________________________________________________________________
    HOSPITAL __________________________________________________________________________
    EMAIL ADDRESS __________________________________________________________________________
    CONTACT NO/S. (Please include Mobile No./s) __________________________________________________________________________

    B. PROFESSIONAL DATA
    SPECIALTY ___________________________ [ ] FELLOW [ ] DIPLOMATE [ ] MEMBER
    SUB-SPECIALTY ___________________________ [ ] FELLOW [ ] DIPLOMATE [ ] MEMBER
    PRC NO. ___________________________ TIN NO. ___________________________
    PHIC NO. ___________________________ VALID FROM _____________ UP TO _____________

    C. HOSPITAL/CLINIC AFFILIATION (WITH REGULAR CLINIC SCHEDULE)


    HOSPITAL/CLINIC NAME ROOM NO. SCHEDULE (DAY-TIME)
    1.) _________________________________________
    _____________ Sun ____ M_____ T_____ W______ Th_____ F_____ Sat_____
    2.) _________________________________________
    _____________ Sun ____ M_____ T_____ W______ Th_____ F_____ Sat_____
    3.) _________________________________________
    _____________ Sun ____ M_____ T_____ W______ Th_____ F_____ Sat_____
    4.) _________________________________________
    _____________ Sun ____ M_____ T_____ W______ Th_____ F_____ Sat_____
    5.) _________________________________________
    _____________ Sun ____ M_____ T_____ W______ Th_____ F_____ Sat_____

    D. OTHER HOSPITAL/CLINIC (VISITING)


    HOSPITAL/CLINIC NAME ROOM NO. SCHEDULE (DAY-TIME)
    1.) _________________________________________
    _____________ Sun ____ M_____ T_____ W______ Th_____ F_____ Sat_____
    2.) _________________________________________
    _____________ Sun ____ M_____ T_____ W______ Th_____ F_____ Sat_____
    3.) _________________________________________
    _____________ Sun ____ M_____ T_____ W______ Th_____ F_____ Sat_____
    4.) _________________________________________
    _____________ Sun ____ M_____ T_____ W______ Th_____ F_____ Sat_____
    5.) _________________________________________
    _____________ Sun ____ M_____ T_____ W______ Th_____ F_____ Sat_____
    I hereby agree to be affiliated in all hospitals and clinics written in this form.
    I certify that all my information written above are TRUE and CORRECT.
    I give my consent to the PAHMOC to gather, use, share, store, and dispose of my personal and sensitive information in

    ___________________________________________ _________________________
    Physician Signature over Printed Name Date

    APPROVING OFFICERS (NAME AND SIGNATURE)


    PCP PAHMOC
    ____________________________________________ ________________________________________________
    Chapter President's Signature over Printed Name Authorize Representative's Signature over Printed Name

    NOTE: ATTACHED ARE THE FOLLOWING DOCUMENTARY REQUIREMENTS


    _______ BIR Certificate of Registration (Form 2303) _______ Curriculum Vitae
    _______ Updated PRC ID _______ Diplomate/Fellow Certificate
    _______ Updated PHIC ID _______ Signed Data Privacy Consent Form
    (Revision 01_Dec. 2020)

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