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: ……………………………………………………………………………………………………… ………………………………………………………………………………………………………..

No 8. Newton Street Windhoek, Namibia P. O. Box 11974 Klein Windhoek Tel: 264 – 61 – 257211/2 Fax: 264 – 61 – 257213 Mail: info@namaf.org.na Website: www.namaf.org.na

Conditions:

Submission of application form does not provide automatic access to a practice number.

The process of granting a healthcare provider with a practice number is subject to the completeness of this document.

Failure to complete the form in full and submit all supporting documentation may result the processing of your application being delayed. NAMAF will not accept any responsibility for incomplete submissions.

Should a practice number be granted / renewed it will be done on the assumption that all information contained herein is of a truthful nature and therefore correct.

PRACTICE NUMBER APPLICATION

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KINDLY COMPLETE THIS FORM IN PEN, IN A CLEAR AND LEGIBLE PRINT. ALL PHOTOCOPIES OF DOCUMENTS MUST BE CERTIFIED.

FAXED OR E-MAILED APPLICATIONS WILL NOT BE CONSIDERED

APPLICATIONS WILL NOT BE PROCESSED UNLESS ALL REQUIRED

DOCUMENTS ARE ATTACHED.

NO CASH PAYMENT WILL BE ACCEPTED. ONLY CROSSED CHEQUES ISSUED TO NAMAF OR PROOF OF ELECTRONIC FUNDS TRANSFER OR PROOF OF DIRECT BANK DEPOSITS WILL BE ACCEPTED AS VALID PROOF OF PAYMENT.

The following information is required for the allocation of a NAMAF practice number:

A. ALL APPLICANTS:

1. Certified copy of valid professional registration with the relevant Health Professions Council of Namibia.

2. Certified copy of Namibian Identity Document / Namibian Passport /

Namibian Work Permit / Namibian Permanent Resident Permit.

3. Certified copy of Marriage Certificate. (If name on certificates differs with the names provided on the professional registration).

4. Certified copy of valid Health Registration Certificate, as issued by the

Ministry of Health and Social Services. (All healthcare practitioners must 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.)

Inquiries in this regard must be directed to the Health Facility Regulation Directorate of the Ministry of Health & Social Services.

5. Certified copies of valid dispensing license issued by the Medicines Regulatory

Control Council should be provided with the practice number application, where applicable.

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B. COMMUNITY or HOSPITAL PHARMACY:

1. Certified copies of appointment certificate of Responsible Pharmacist;

2. Certified copies of Community or Hospital Pharmacy Registration issued

by Pharmacy Council of Namibia; and

3. Certified copies of Health registration certificate issued by MoHSS.

C. GROUP OR MULTI-DISCIPLINARY PRACTICES: In group or multi-disciplinary practices, all healthcare practitioners must each apply separately for an individual practice number and then a joint application must be submitted for the group or multi-disciplinary practice number. D. HEALTHCARE PRACTITIONERS IN THE EMPLOYMENT OF GOVERNMENT: NAMAF does not allocate practice numbers to Government employed healthcare practitioners unless the following documentation are provided:

1. Certified copy of Limited Private Practice permission from the Permanent

Secretary of the Ministry where the healthcare practitioner is employed.

OR

2. If the practitioner has resigned from Government employment, a copy of

the letter from the relevant Ministry confirming such resignation.

E. HOSPITALS:

1. Certified copy of valid 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).

3. The practicing healthcare practitioner in these departments must provide

certified copies of:

i. their Namibian professional Registration Certificates, ii. License/Registration Certificate as allocated by MOHSS,

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iii. Namibian ID/Passport or iv. Work Permit, and v. marriage certificate if the names on the application is different from

that on the healthcare practitioners proof of professional registration.

F. HEALTH FACILITIES:

1. Certified copy of valid Health Registration Certificate issued 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).

3. The practicing healthcare practitioners in these departments must provide certified copies of:

i. Professional Registration with relevant HPCNA, ii. License/Registration certificate issued by MOHSS, iii. Namibian ID/Passport iv. Work Permit, and v. marriage certificate if the names on the application are different from

that on the practitioner’s proof of professional registration. G. AMBULANCES:

1. Certified copies of identity documents of all ambulance personnel; and/or

2. Certified copies of valid passport/s of all ambulance personnel;

3. Certified copies of valid work permit or permanent residence in case of

ambulance personnel that are not Namibian citizens;

4. Certified copies of proof of professional registration of all ambulance

personnel;

5. Updated number of vehicles to be used as ambulances and certified

copies of vehicle road worthy;

6. Certified copies of driver’s licenses of all ambulance service staff

registered with the Allied Health Professions Council of Namibia;

7. Certified copies of proof of defensive driver training by an accredited

institution of all vehicle operators;

8. Certified copy of Health Registration Certificate issued by MoHSS with an

indication of the allowed scope (Basic, Intermediate or Advanced Life

Support);

9. Employment contracts/confirmation for each registered staff member;

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H. 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 practice number annually, which means that your number could be deleted from the PCNS.

POSTAL

ADDRESS:

SUBURB:

TOWN:

COUNTRY:

POSTAL CODE:

I. PHYSICAL ADDRESS OF PRACTICE:

NUMBER OF OFFICE/

HOUSE/ FLAT, ETC:

STREET NAME:

SUBURB:

TOWN:

COUNTRY:

J. STARTING DATE OF PRACTICE:

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K. IF JOINING AN EXISTING GROUP OR MULTI-DISCIPLINARY PRACTICE, PROVIDE PRACTICE NUMBER OF SUCH GROUP OR MULTI-DISCIPLINARY PRACTICE:

L. IS THIS A SOLUS OR GROUP OR MULTI-DISCIPLINARY PRACTICE?

SOLUS

GROUP OR MULTI-DISCIPLINARY

NOTE FOR GROUP OR MULTI-DISCIPLINARY PRACTICE:

(a) For a Group or Multi-Disciplinary 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) If a member of the group or multi-disciplinary practice does not

possess a personal practice number, he/she must apply separate from the group or multi-disciplinary practice to get such a personal number.

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INDIVIDUAL PRACTICE NUMBERS OF EXISTING MEMBERS: 1.………………………………………………………………….……………………….……………………………………………………………………….…………………….. 2………………………………………………………………….……………………………….………………………………………………………………….…………………… 3………………………………………………………………….……………………………….………………………………………………………………….……………………. 4…………………………………………………………………………………………………...………………………………………………………………………………………

NOTE: Each individual member will use his/her personal practice number when submitting claims to the Medical Aid Funds in respect with patients treated by him/her for identification of the treating Practitioner in respect of all claim submitted to the Funds. Such claims will however be remitted under the banking details of the group or multi-disciplinary practice number.

L. IF YOU HAVE AN EXISTING PRACTICE NUMBER PLEASE PROVIDE THIS NUMBER.

If you had a practice number previously whether it is a SADC or NAMAF number, this must be indicated.

NAMIBIAN PRACTICE NUMBER:

SADC PRACTICE NUMBER:

DATE OF CLOSURE OF PRACTICE: (If you have left a partnership practice kindly indicates the partnership’s practice number.

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M. PRACTICE DETAILS:

(This applies to the new practice).

AREA CODE:

TELEPHONE NO:

FAX NO:

CELL PHONE NO:

EMERGENCY TEL. NO:

E-MAIL ADDRESS:

N. 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:

…………………………………….

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How many beds does the hospital have? …………………… How many wards does the hospital have? ……………………..

O. PROFESSIONAL COUNCIL 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 relevant HPCNA. A certified copy of the relevant certificate MUST be attached tot his application)

HEALTHCARE PRACTITIONER NAME AND RELEVANT HPCNA REGISTRATION NUMBER (S): (Practitioners in group or multi-disciplinary practices must list individual names and HPCNA registration numbers of all members)

1………………………………………………………………… ………………………………………………………………… 2………………………………………………………………… ………………………………………………………………… 3………………………………………………………………… ………………………………………………………………… 4……………………………………………………….............. ………………………………………………………............... ………………………………………………………...............

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P. BANKING DETAILS

(This is to facilitate speedy payment by Medical Aid Funds. Claims submitted by healthcare practitioners in group or multi-disciplinary practices will be remitted under the group or multi-disciplinary practice number).

ACC NAME:

ACCOUNT NO:

BANK:

BRANCH NAME:

BRANCH CODE:

TYPE OF ACC:

PLEASE ATTACH WRITTEN PROOF OF BANKING DETAILS Q. 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 made out to NAMAF and direct bank deposits or Electronic Funds Transfer, will be accepted as legitimate proof of payment. No cash payments will be accepted) Account Name: NAMAF Bank: FNB Namibia (Commercial Branch) Account Number: 62241926354 Branch Code: 281972 (Please send proof of payment with your application form)

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R. ANNUAL REGISTRATION FEE: Please note that, to maintain your practice number on the PCN system, an

Annual Renewal Fee as would be determined by NAMAF Management Committee from time to time and published in Government Gazette, payable to NAMAF, shall be charged on an annual basis. An invoice shall be mailed to you at the beginning of each year. An annual renewal payment must be done by 31st March, failing to affect such payment will result in the suspension of your practice number on the PCN system by the 30th July annually. Note, it is VERY important that healthcare practitioners keep NAMAF informed of their correct contact details.

Cash payments will not be accepted.

T. NOTES ON PRACTICE CODE NUMBERING SYSTEM AND PRACTICE NUMBERS:

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 healthcare practitioners and/or 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 healthcare provider and/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.

U. CONDITIONS OF USE: 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).

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V. DECLARATION AND ACKNOWLEDGEMENT:

• Submission of the application form serves as an admission of acknowledgement that the applicant has read and understood the contents of this form and that the applicant is in full compliance to all legislative aspects and conditions as referred to in this document, unless otherwise indicated by the applicant.

• Should any of the circumstances of the applicant alter subsequent to the date after filling in this application, prior to or after acceptance of my application, I shall notify NAMAF of the change. I/we acknowledge that failure to do so may lead to the termination or amendments to the terms and conditions under which my/our practice number has been granted.

• Any intentional misfiling or misrepresentation of information contained in this form may result in potential claims to recover any amounts that may have erroneously been paid to a medical professional / facility.

• I/we warrant that the information provided is true and accurate and should my application be accepted, the contents of this application form shall constitute the basis of my agreement with NAMAF.

• I/we hereby consent that all contact details given in this application form and any amendments to those contact details may be used by NAMAF or any appointed agent of NAMAF for sending any information of any nature (confidential or other).

• I/we, the undersigned, hereby acknowledge that I/we have read and understood the conditions and rules pertaining to the issuing of practice numbers by NAMAF and consent of my own free will. I herewith undertake to adhere to these conditions at all times.

• I declare that all information provided on this form, to the best of my/our knowledge is true and accurate, specifically for disclosures. I/we acknowledge that NAMAF relies implicitly on the completeness and truthfulness thereof. Should my application be accepted by NAMAF, the contents of this application shall constitute part of the terms of my agreement with NAMAF.

• I/we acknowledge that should I wish to terminate my practice number with NAMAF, I/we am obliged to notify NAMAF in writing of such termination.

Name: ………………………….. Signature: …………………………….. Date: …………………………………… Scope of Practice: ………………………………………………………………………………….

PRACTICE STAMP

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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