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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 
 
医师执业注册申请审核表
来源: 作者: 发表日期:2015/7/21 17:55:13 访问次数:0
 

医师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:                                   

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

填 表 说 明

1、本表供取得《医师资格证书》后申请医师执业注册使用。

    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3-4由有关部门填写,封面的医师执业证书编码由注册主管部门填写。

    4、表内的年、月、日时间,一律用公历阿拉伯数字填写。

    5、申请执业级别请选填执业医师或执业助理医师。

    6、申请执业类别请选填临床、中医、口腔或公共卫生。

    7、学历应填写与申请类别相应的最高学历。

    8、“相片”一律用近期小二寸免冠正面半身照。

    9、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。

10、取得医师资格证书后二年内首次注册者不填写业务水平考核机构或组织的名称和培训时间及考核结果、考核和培训机构或组织的意见栏目。

11、如填写内容较多,可另加附页。

12、执业范围按《关于医师执业注册中执业范围的暂行规定》填写。

需提交资料及注意事项

(原件现场查验,复印件存档):

1、注册医师的身份证原件及复印件一份;

2、医师资格证原件及复印件一份;

3、拟执业机构《医疗机构执业许可证》复印件一份;

4、半年内二级以上医院的健康体检表原件一份(空表见附件);

5、拟执业机构聘用证明原件一份(空表见附件);

6、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;

7、乡村医生升执业(助理)医师须交回原乡村医生执业证书原件;

8、助理医师升执业医师须交回原执业助理医师执业证书原件;

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

申请执业机构

名称及登记号

申请执业

机构地址

邮政

编码

申请执业类别

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

 

业务水平

考核机构

或组织的

名称和培

训时间及

考核结果

其他要说明的问题

申请人签字:                             

考核和培训

机构或组织

的意见(包

括培训时间

及考核结果

                          

                                

负责人:                                    

执业机构

   

级别:

类别:

拟聘用科目:

负责人:                                    

                                              

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:

                                                      


医师注册健康检查表

体检医院名称:                                  体检日期:               

   

性别

出生日期

体检单位骑缝章

工作单位

民族

既往病史

甲状腺

脊柱

医师签字:

 

四肢

 

关节

泌尿生殖器

 

 

医师签字:

神经及精神

肺及呼吸道

心脏及血管

腹部器官

   

胸部X线透视

医师签字:

   

医师签字:

   

乙肝表面抗原

化验员签字:

矫正

视力

其它

眼疾

医师签字:

鼻及鼻窦

   

   

   

(以下部分请在符合项目上用“”表示:

结果:    1、健康或良好    2、一般或较弱    3、有慢性病

(如有慢性病请继续在下列符合的项目上用“”表示:

1、心血管病          6、结核病

2、脑血管病          7、糖尿病

3、慢性呼吸系统病    8、神经或精神疾病

4、慢性消化系统病    9、其它慢性病(具体):

5、慢性肾炎                                      体检医院盖章

主检医师签字:                         填写日期:              

注册机关意见

注册机关盖章

填报日期:               

注:1、表中内容请体检单位如实工整填写,不得涂改,不得弄虚作假。

2、体检后此表交注册机关。

3X线、心电图、肝功报告单请贴在背面。

医疗、预防、保健机构聘用证明

姓名:

性别:

年龄:

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:

拟聘期限:

聘用单位意见:

单位公章

法人签字:                                                  

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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