Outpatient Medical Center Registration

General

Medical Center Name *

Trade License Number *

Registration Number (MoH / Authority) *

Registration Date

Use YYYY-MM-DD format.

Type of Facility *

Ownership Type *

Contact

Country

City

Full Address *

Google Map Location (URL)

Website

Landline Number

Mobile Number

WhatsApp Number

General Email Address *

Administrative

Administrative Contact Full Name *

Administrative Contact Position

Administrative Contact Direct Phone

Administrative Contact Email Address *

Medical Director

Medical Director Full Name *

Medical Director Specialty

Medical Director License Number

Medical Director Years of Experience

Medical Director Contact Number

Medical Director Email Address

Services

Services & Specialties Offered

Other Specialty / Service

Facility

Total Area (sqm)

Number of Consultation Rooms

Number of Procedure Rooms

Number of Beds (if applicable)

Operating Hours

Example: Monday to Friday, 8:00 AM to 6:00 PM

Emergency Services Available

YesNo

Gallery

Upload up to 4 images

Diagnostic

Available Diagnostic & Equipment

Other Diagnostic / Equipment

Billing

Previously Contracted with Insurance Companies

YesNo

List of Existing Insurance Partners

Billing Contact Person

Billing Email

Claims Submission Method

Average Daily Patient Volume

Bank Details

Bank Name

Account Name

Account Number

IBAN

SWIFT Code

Documents

Trade License Copy *

File name:

File size:

Medical License *

File name:

File size:

Accreditation Certificates

File name:

File size:

List of Doctors with Licenses

File name:

File size:

Facility Photos

File name:

File size:

Insurance Certificates (if any)

File name:

File size:

Declaration

Declaration Notice

We hereby confirm that all information provided is accurate and agree to comply with the insurance company’s policies and procedures.

I confirm and accept the declaration

ConfirmedNot confirmed

Authorized Signatory Name *

Authorized Signatory Position *

Authorized Signatory Signature

Type full name as e-signature.

Declaration Date

Use YYYY-MM-DD format.

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