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医保
2015/7/21 17:05:00 
遂宁本地的可以!...
2015/7/21 17:32:35 
 
医师变更执业注册申请审核表
来源: 作者: 发表日期:2015/7/21 17:53:01 访问次数:0
 

医师变更执业注册申请审核表

              名:                                   

医师资格      级别:                                   

                  类别:                                   

医师资格证书编码:                              

原医师执业证书编码:                                    

新医师执业证书编码:                                   

填表时间:           

联系电话:                        

中华人民共和国卫生部监制


1、本表供变更医师执业注册事项使用。

    2、一律用钢笔或毛笔填写,内容要具体、真实,字迹要端正清楚。

3、封面、表1-2由申请人填写,表3-5由有关部门填写,封面的新医师执业证书编码由注册主管部门填写。

4、跨省、自治区、直辖市变更执业注册事项的填写封面的新医师执业证书编码。

    5、表内的年、月、日时间,一律用公历阿拉伯数字填写。

    6、申请执业级别请选填执业医师或执业助理医师。

    7、执业类别请选填临床、中医、口腔或公共卫生。

    8、学历应填写与申请类别相应的最高学历。

    9、“相片”一律用近期二寸免冠正面半身照。

10、申请变更执业地点的,申请人需在拟变更执业注册事项中填写拟变更的医疗机构名称、登记号、地址及邮政编码

11、填写栏目中聘用科目时,申请临床、口腔类别的按《医疗机构诊疗科目名录》一级科目填写;申请中医类别的,按《医疗机构诊疗科目名单》二级科目填写;申请公共卫生类别的,参照公共卫生医师职业分类填写。

12、如填写内容较多,可另加附页。

需提交资料及注意事项

(原件现场查验,复印件存档):

1、如为医疗机构法人、负责人变更,则需交回原《医疗机构执业许可证》正副本原件;

2、身份证原件及复印件;

3、医师资格证书及执业证书原件及复印件;

4、委托办理的委托书(单位加章)及受委托人身份证原件及复印件;

5、医师变更执业注册申请审核表(县内变更一式一份,县内到县外、市外、省外的一式两份);

6、拟执业机构聘用证明;

7、拟执业机构《医疗机构执业许可证》复印件;

8、与拟变更的执业范围相应的高一层次毕业学历或者培训考核合格证明;

9、所有复印件需注明“复印件与原件一致”字样,并加盖拟执业机构鲜章;

   

       

照片

出生年月

       

   

所学系、专业

家庭地址及

邮政编码

专业技术职务

任职资格

身份证号码

原执业

机构名称

及登记号

原执业

机构地址

邮政

编码

原执业

级别

原执业

类别

获得执业

助理医师资格

的时间

获得执业医师资格的时间

何时何地因何种原因受过何种处罚或处分

   

     

技术职务

身体和健

康状况

其他要说

明的问题

申请人签字:                             

拟变更注

册事项

                          

变更注册

理由

                              

申请人签字:                                

原执业机构

   

负责人:                                    

                                              

原执业机构

上级主管

部门审批

   

负责人:                                    

                                                

原注册卫生

行政部门

审批意见

                          

                                

负责人:                                    

拟执业机构

   

级别:

类别:

拟聘用科目:

     

负责人:                                       

拟执业机构

上级主管

部门审批

   

级别:

类别:

拟聘用科目:

     

负责人:                                       

卫生行政

部门审批

   

执业机构及登记号:

  机构地址及邮编:

  级别:

  类别:

  聘用的科目:

                                

负责人:                                    

医师执业

证书编码

执业医师

执业助理医师

领证人签字:

                                                

附件1

  

  

  

医师级别(执业、助理):

医师类别(临床、口腔、公卫、中医):

医师资格证书编码:

受聘专业(按医师注册执业范围填写):

受聘时间:

受聘期限:

聘用单位意见:

法人签字:                                             单位公章:

                                                               

  注:本表一式二份,一份交注册主管部门,一份留存聘用单位。

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