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Please note that in case the application form is found ...
Please note that in case the application form is found ...
Please note that in case the application form is found ...
Please note that in case the application form is found ...
Please note that in case the application form is found ...
Please note that in case the application form is found ...
Please note that in case the application form is found ...
Please note that in case the application form is found ...
Please note that in case the application form is found ...
Please note that in case the application form is found ...
Please note that in case the application form is found ...
Please note that in case the application form is found ...
Please note that in case the application form is found ...
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  • 1. HEALTH FACILITY LICENSING APPLICATION FORM Please note that in case the application form is found incomplete and incoherent will not be approved. Health Authority – Abu Dhabi Office Use Only: Health Facilities Licensing Department Reference. N. _____________ P.O.Box: 5674 Zone: _____________ Abu Dhabi Date Received: _____________ Tel: (2) 419-33333 Fax: (2) 444-9822 SECTION 1 – GENERAL INFORMATION Type of Application  New License  Changing Facility type  Other:_____________________ Commercial Name Location Street: Sector: City: Plot #:  Dedicated Building  Villa  Flat/Suite Owner Name: Position: / Official Representative Tel: Fax: Mobile: e-mail: (Please fill the PRO Form) Type of Facility  Hospital  Centre  Clinic/ Polyclinics  Rehabilitation centre  Provision of health services  Diagnostic centre  Other: __________________________ Status  Independent Entity  Satellite Entity Affiliation Expected Date of Starting the project Commissioning the Facility Total Project Cost Item Value (AED) Construction Cost Medical Equipment Cost Furniture and Office Equipment Vehicles & Transportation Equipment Working Capital Pre-Operation Cost First Year Operating Cost TOTAL INVESTMENT Shareholders Equity Participation _____% Balanced Secured through Loans ______% Page No. 1
  • 2. HEALTH FACILITY LICENSING APPLICATION FORM SECTION 2 – HOSPITAL  Nursing home  General Hospital  One day surgery  Specialized Hospital  Convalescence house  Rehabilitation Scope of Services (Please specify in sections 8, 9, 10 and 11 the services to be provided) Hospital Capacity Beds Outpatient Services Operating Room O.T. Consultation Rooms: Recovery Room Beds Treatment Rooms: Delivery Room Rooms Specialized Clinics: (Please specify in section 9) Beds Allocation Wards Critical Care Units Geriatric Beds Burns Unit Beds Gynaecology Beds CCU Beds Medicine Beds CICU Beds Obstetric Antenatal Beds ICU Beds Obstetric Postnatal Beds NICU Beds Paediatric Beds PICU Beds Psychiatry Beds Step-Down Unit Beds Surgery Beds Isolation Unit/Rooms Beds Accident Emergency  Triage [Cubicles]  Fast Track [Rooms]  Isolation Rooms  Observation [Beds]  Resuscitation [Beds]  Treatment Rooms Diagnostic (Please specify in sections 10& 11) equipment Staffing Please specify in section 12 SECTION 3 – CENTER  Dental Centre  Medical Centre Scope of Services Please specify in sections 8 ,9 ,10and 11 the scope of services to be provided Clinics Consultation Rooms Treatment Rooms Diagnostic equipment  X-ray Medical Diagnostic equipment  Medical Laboratory equipment Staffing Please specify in section 12 Page No. 2
  • 3. HEALTH FACILITY LICENSING APPLICATION FORM SECTION 4 – REHABILITATION CENTRE  Optical shop  Dental laboratory  Audiometric & optical shop  Physiotherapy  Prosthetic & Orthotics  Esthetical Scope of Services Please specify in sections 9 the scope of services to be provided Clinics Consultation Rooms Treatment Rooms Staffing Please specify in section 12 SECTION 5 – DIAGNOSTIC CENTER  Medical Diagnostic Imaging  Medical Laboratory Scope of Services Please specify in sections 10 and 11 the scope of services to be provided Staffing Please specify in section 12 SECTION 6 – CLINIC/ POLYCLINIC  General Clinic  Polyclinic  Specialized Clinic  Other:____________ Scope of Services Please specify in sections 8 and 9 the scope of services to be provided Clinics Consultation Room(s) Treatment Room(s) Staffing Please specify in section 12 Page No. 3
  • 4. HEALTH FACILITY LICENSING APPLICATION FORM SECTION 7 –POVISION OF HEALTH SERVISES  Health consulting services &  Medical skill training hospital management  Medical transport service :-  Patient Escort services o Vehicle Ambulance  International Air Ambulance o Helicopter emergency medical service(HEMS)  Employing/Transferring the medical staff  Home care services Staffing Please specify in section 12 SECTION 8 – VOCATION Specialties  Anaesthesia  Obstetrics & Gynaecology  Pharmacy  Dental  Medical Diagnostic Imaging  Psychiatry  Family Medicine  Medical Laboratory  Surgery  General Medicine  Paediatric  Others: __________________  Internal Medicine  Rehabilitation ________________________ Sub-specialties Anaesthesia  General  Cardiac  Obstetric Alternative Medicine  Chiropractic Medicine  Homeopathic Medicine  Traditional Medicine  Folk Medicine NOT LICENSED TILL FURTHER NOTICE Medicine  Osteopathic  Tropical  Herbal Medicine  Traditional Chinese Medicine  Ozone Therapy Dental  General Dentistry  Oral Surgery/ Surgical Dentistry  Prosthodontics  Endodontics  Pediatric Dentistry  Restorative Dentistry  Orthodontics  Periodontology Other: __________________ Internal Medicine  Allergy  Gastroenterology & Hepatology  Neurology  Cardiology  Endocrinology & Metabolism  Nephrology  Non-invasive Cardiology  Haematology  Pulmonology  Dermatology  Infection Disease  Rheumatology  Geriatric  Intensive Care Other: __________________ Obstetric and Gynaecology  Maternal and Foetal  Reproductive Medicine  Sexual & Reproductive Medicine Health Page No. 4
  • 5. HEALTH FACILITY LICENSING APPLICATION FORM Oncology  Medical Oncology  Surgical Oncology  Radiation Therapy  Gynaecologic Oncology  Uro-Oncology Other: _________________  Haematology- Oncology  Bone Marrow Transplant Paediatric  General Paediatric  Gastroenterology &  Ophthalmology  Cardiac Surgery Hepatology  Orthopaedic  Cardiology  Neonatology  Paediatric Surgery  Non-invasive Cardiology  Nephrology  Psychiatry  Haematology-Oncology  Neurology  Pulmonology  Endocrinology & Metabolism  Neurosurgery  Urology Surgery  Cardiac Surgery  Ophthalmology  Otolaryngology  Valve Repair  General Ophthalmology  General ENT  Aortic Surgery  Corneal Refractive  Head & Neck Surgery  Arrhythmias Surgery  Orbital Reconstruction  Rhinology  Minimally Invasive &  Glaucoma  Snoring Robotic Surgery  Retina  Endoscopy Skull  General Surgery  LASIK Base  Abdomen Surgery  Ocuplastic  Cochlear Implantation  Endocrine Surgery  Squint  Middle Ear Surgery  Colon & Rectal Surgery  Congenital Glaucoma  Plastic Surgery  Maxillofacial  Cataract  Cosmetic  Cosmetic  Phacoemulsification  Reconstruction  Reconstructive  Orthopaedic  Vascular & Endovascular  Neurosurgery  General Orthopaedic  Urology  Epilepsy Surgery  Arthroplasty  General Urology  Stereotactic Biopsy  Arthroscopy  EndoUrology  Trauma  Spine Surgery  Urodynamics  Vascular Neurosurgery  Foot Surgery  Uro-gynecology  Neurodegenerative  Hand Surgery  Reconstructive Urology Disorders  Hip Replacement  Thoracic Surgery  Limb lengthening  Sports Medicine SECTION 9 – SUPPORT CLINICAL SERVICES Specialized Clinics Ambulatory Care Services Rehabilitation Services  Allergy Clinic  Dialysis  Speech Therapy  Andrology  ESWL  Neuro-rehabilitation  Breast Cancer Screening  Day Surgery  Physiotherapy  Cervical Cancer Screening  Women’s Health  Occupational Therapy  Obesity Clinic  In-Vitro Fertilization (IVF)  Ergo therapy  Dietetic  Home Care Services  Prosthetics & Orthotics  Diabetes  Others: ____________  Psychotherapy  Immunisation  Hydrotherapy  Wound’s Clinic  Others:_______________  Others: ____________ Others  e-consultation Services  Pulmonary Functions Laboratory  EEG/EMG/VEP  Oral Hygiene  Audiology  Sleep Disturbances Lab.  Dental Laboratory  Electrocardiography  Epilepsy Unit  Optometry  Stress Test  Other: ___________________ Page No. 5
  • 6. HEALTH FACILITY LICENSING APPLICATION FORM  Inpatient Pharmacy  ERG/EOG/VOP Page No. 6
  • 7. HEALTH FACILITY LICENSING APPLICATION FORM SECTION 10 – MEDICAL LABORATORY Scope Services  Low Complexity Tests  Anatomic Pathology  Blood Bank  Clinical Chemistry  Cytogenetics  Hematology  Histocompatibility  Immunology  Microbiology  Molecular Biology  Phlebotomy  Others, _____________________ SECTION 11 – MEDICAL DIAGNOSTIC IMAGING SERVICES  Radio-Diagnostic  Ultrasound  General Radiography ( ____ )  General ( ___ )  Fluoroscopy ( ____ )  Doppler ( ___ )  Interventional Radiology ( ____ )  Obstetric ( ___ )  Panoramic ( ____ )  Cardiac ( ___ )  Mammography ( ____ )  CT Scan ( ___ )  Nuclear Medicine  MRI ( ___ Tesla)  Single-Head Camera ( ___ )  Open System  Dual-Head Camera ( ___ )  Close System  PET Scan ( ___ )  Cardiac Catheterization Lab.  PET-CT Scan ( ___ )  Single Plane ( ___ )  Bone-densitometry ( ___ )  Dual Plane ( ___ ) Page No. 7
  • 8. HEALTH FACILITY LICENSING APPLICATION FORM SECTION 12 – MEDICAL STAFFING Physicians ______ Dentist ______ Nursing ______ Clinical Support Staff ______ Physicians  Allergy ( _____ )  Neurosurgery ( _____ )  Alternative Medicine ( _____ )  Nuclear Medicine ( _____ )  Anaesthesia ( _____ )  Obstetric & Gynaecology ( _____ )  Anatomic Pathology ( _____ )  Oncology ( _____ )  Audiological Medicine ( _____ )  Ophthalmology ( _____ )  Cardiac Surgery ( _____ )  Orthopaedic ( _____ )  Cardiology ( _____ )  Osteopathic ( _____ )  Cardiology (Non-invasive) ( _____ )  Otolaryngology ( _____ )  Chiropractic Medicine ( _____ )  Paediatric Medicine ( _____ )  Clinical Chemistry ( _____ )  Paediatric Cardiology ( _____ )  Clinical Immunology ( _____ )  Paediatric Cardiac Surgery ( _____ )  Clinical Pathology ( _____ )  Paediatric Endocrinology ( _____ )  Dermatology ( _____ )  Paediatric Gastroenterology ( _____ )  Emergency Medicine ( _____ )  Paediatric Nephrology ( _____ )  Endocrinology ( _____ )  Paediatric Neurology ( _____ )  Family Medicine Physician ( _____ )  Paediatric Neurosurgery ( _____ )  Folk Medicine ( _____ )  Paediatric Oncology ( _____ )  Gastroenterology ( _____ )  Paediatric Ophthalmology ( _____ )  General Medicine ( _____ )  Paediatric Orthopaedic ( _____ )  General Surgery ( _____ )  Paediatric Surgery ( _____ )  Geriatric ( _____ )  Paediatric Urology ( _____ )  Haematology ( _____ )  Plastic Surgery ( _____ )  Herbal Medicine ( _____ )  Psychiatry ( _____ )  Homeopathic Medicine  Radiology ( _____ )  Infection Diseases ( _____ )  Respiratory ( _____ )  Intensive care ( _____ )  Rheumatology ( _____ )  Maxillofacial Surgery ( _____ )  Traditional Chinese Medicine ( _____ )  Medical Microbiology ( _____ )  Tropical Medicine ( _____ )  Neonatology ( _____ )  Urology ( _____ )  Nephrology ( _____ )  Vascular Surgery ( _____ )  Neurology ( _____ )  Other: _______________________ ( _____ ) Dentist  General Practitioner ( _____ )  Orthodontics ( _____ )  Dental Public Health ( _____ )  Pediatric Dentistry ( _____ )  Endodontic ( _____ )  Periodontology ( _____ )  Oral Medicine ( _____ )  Prosthodontics ( _____ )  Oral & Maxillofacial Surgery ( _____ )  Restorative Dentistry ( _____ )  Oral Surgery/ Surgical Dentistry ( _____ )  Other ______________________ ( _____ ) Nursing  Registered Nurse ( _____ )  Registered Midwife ( _____ )  Practical Nurse ( _____ )  Practical Midwife ( _____ )  Dental Nurse ( _____ )  Other ______________________ ( _____ ) Page No. 8
  • 9. HEALTH FACILITY LICENSING APPLICATION FORM Clinical Support Staff  Anaesthesia Technician ( _____ )  Nuclear Medicine Technologist ( _____ )  Audiologist ( _____ )  Occupational Therapist ( _____ )  Dental Technician ( _____ )  Optometrist ( _____ )  Dental Assistant ( _____ )  Perfusionist (_____)  Dental Hygienist ( _____ )  Pharmacist ( _____ )  Dietician ( _____ )  Pharmacist (in charge) ( _____ )  Pharmacy Technician ( _____ )  ECG Technician ( _____ )  EEG Technician ( _____ )  Physiotherapist ( _____ )  Emergency Medicine Technician ( _____ )  Physiotherapy Technician ( _____ )  Haematology Lab. Technologist ( _____ )  Podiatrist ( _____ )  Histopathology Lab. Technologist ( _____ )  Psychologist ( _____ )  IVF Medical Technologist ( _____ )  Radiographer ( _____ )  Medical Lab. Technologist ( _____ )  Radiology Technician ( _____ )  Microbiology Lab. Technologist ( _____ )  Respiratory Therapist ( _____ )  Molecular Biology Medical Laboratory  Speech Therapist ( _____ ) Technologist ( _____ )  Social Worker ( _____ ) Complimentary & Alternative Medicine Staff Specialty Physician Therapist Assistant Therapist Technician  Chiropractic Medicine ( _____ ) ( _____ ) ( _____ ) ( _____ )  Folk Medicine ( _____ ) ( _____ ) ( _____ ) ( _____ )  Herbal Medicine ( _____ ) ( _____ ) ( _____ ) ( _____ )  Homeopathic Medicine LICENSED TILL NOT ( _____ ) FURTHER ( _____ ) NOTICE ( _____ ) ( _____ )  Osteopathic ( _____ ) ( _____ ) ( _____ ) ( _____ )  Traditional Chinese Medicine ( _____ ) ( _____ ) ( _____ ) ( _____ )  Traditional Medicine ( _____ ) ( _____ ) ( _____ ) ( _____ )  Tropical Medicine ( _____ ) ( _____ ) ( _____ ) ( _____ ) SECTION 13 – TERMS & CONDITIONS Medical Laboratory Please Refer to Appendix A to list lab tests to be provided. For guidelines, rules and regulations (tests lists, staffing requirements, applicable JCIA standards or equivalents, quality assurance, proficiency test) Medical Diagnostic Please Refer to Appendix B to list medical diagnostic imaging exams that Imaging you intent to provide. For guidelines, rules and regulations list of exams, staffing requirements, applicable JCIA standards or equivalents, quality assurance, quality assurance tests) Medical Equipment Please Refer to Appendix C to list the major medical equipment that will be installed. It is mandatory to submit with the functional program and engineering drawings a detailed list of medical equipment enclosing the manufacturers’ footprints of major equipment; Facility Location Please specify the facility location and submit copy of the site plan. For further information, click on www.haad.ae/haad/ Page No. 9
  • 10. HEALTH FACILITY LICENSING APPLICATION FORM I, __________________________, ______________________, hereby certify or affirm that: Applicant Name & Surname Title of Applicant 1- The information provided in this application is complete and accurate; 2- All official documents required by HA-AD are enclosed; 3- Upon the approval of the application (proposed project), the functional program, detailed design with all engineering drawings of the facility, shall be submitted to Health Facilities Licensing Department at HA-AD within Twelve (12) months as of the date of the preliminary License;: 4- In case, the detailed functional program, facility design and drawings are not submitted with the time limits specified here-above in point 3 (12 months), the application becomes void and a new one shall be submitted. 5- The associated fees to the review of the facility design and drawings, and to the final inspection of the facility prior to its commissioning will be fully paid by the applicant. 6- As a result of the final inspection of the facility by a technical taskforce of HA-AD (that can be one of HA-AD Preferred Provider of Consultancy Services “PPC”) ensuring its compliance with the adopted international technical standards, a Certificate of Good Operation “CGO" is issued upon which the Health Facilities Licensing Department at HA-AD deliver the final license to commission the facility. I acknowledge and attest that the facility: 1- Medical professional staff qualifications will meet the HA-AD PQR; 2- Will deploy and maintain HA-AD’s health care quality standards; 3- Will comply with all HAAD’s policies, rules and regulations; 4- Will implement best recognized healthcare practices to manage health information, patient and staff safety, quality improvement from all perspectives; 5- Will provide Health Facilities Licensing Department at HA-AD monthly and yearly statistical reports upon facility commissioning; Applicant Stamp Owner Name/ official Owner Signature/ official Application Date representative representative For Official USE  Approved  Incomplete, further information required  Not Approved Comments: Chairman of Health Facilities Head of Health Facilities Licensing Director of Policy & Licensing Taskforce Department Regulation Page No. 10
  • 11. HEALTH FACILITY LICENSING APPLICATION FORM APPENDIX A – MEDICAL LABORATORY TESTS LIST Anatomic Pathology Blood Bank and Transfusion Clinical Chemistry Haematology Microbiology Molecular Biology Others Page No. 11
  • 12. HEALTH FACILITY LICENSING APPLICATION FORM APPENDIX B – MEDICAL DIAGNOSTIC IMAGING EXAMS LIST Radio-diagnostic (Radiography, CT, Mammography, Panoramic, Peripheral Angiography, etc.) Ultrasound (Abdominal, Pelvic, Obstetric, Cardiac, etc.) Nuclear Medicine MRI Cardiac Catheterization Laboratory Others Page No. 12
  • 13. HEALTH FACILITY LICENSING APPLICATION FORM APPENDIX C – MAJOR MEDICAL EQUIPMENT LIST Diagnostic (X-ray, ultrasound, lab analyzer, EKG, EEG, endoscope, etc.) Electro-Medical (electrical bed, dental chair, autoclave, surgical light, surgical table etc.) Monitoring (cardiac monitor, foetal monitor, NIBP, etc.) Therapeutic (defibrillator, ventilator, anaesthesia machine, diathermia, ESWL, etc.) Page No. 13

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