I. Instructions for filling out the form:
1. This form is for the use of the change of physician registration matters.
2, always fill in with a pen or brush, the content should be specific, true, handwriting should be correct and clear.
3, the cover, tables 1-2 filled out by the applicant, tables 3-5 filled out by the relevant departments, the cover of the new physician's license code filled out by the registration department.
4, across the provinces, autonomous regions and municipalities directly under the Central Government to change the practice of registration matters to fill in the cover of the new physician's license code.
5, the table of the year, month and day time, always fill in the calendar Arabic numerals.
6, apply for practice level please fill in the licensed physician or physician assistant.
7, apply for practice category please fill in clinical, Chinese medicine, dental or public **** health.
8, education should be filled with the application category corresponding to the highest degree.
9, "photo" always use the recent two-inch bareheaded front half-body photo.
10, applying for a change of place of practice, the applicant is required to change the practice of registered matters to be filled in the proposed change in the name of the medical institution, registration number, address and postal code.
11, fill in the column of employment subjects, apply for clinical, dental category by the "medical institutions diagnostic and treatment subjects directory" first-class subjects; apply for the category of Chinese medicine, according to the "medical institutions diagnostic and treatment subjects directory" second-class subjects to fill in; apply for the category of public **** health, with reference to the occupational classification of the public **** health practitioners to fill in.
12, such as filling out more content, can be added to the attached page.
Two, "physician change practice registration application review form" (template)
Surname? First name:
Physician qualification level:
Category:
Physician qualification certificate code:
Original physician's license code:
New physician's license code:
Fill out the form: year? Month? Day
Ministry of Health of the People's Republic of China
Expanded Information:
Required materials for change of registration:
1. "Physician application for registration of change of practice review form"
2. "Physician's original certificate of practice"
3. "Physician's change of notification" issued by the Department of Health of the original unit (bureau) and the original data diskette of the registration of the person.
4. A two-inch photo is required for the change of foreign personnel.
5. Change of registration fee and information fee of 20 yuan / person.
References:
Application for Registration of Physician Practitioner and Change of Practice Audit Form
Ministry of Health - Interim Measures for Registration of Physician Practice (Ministry of Health Decree No. 5)