Provider Payee Number Renewal Form

RENEWAL REMINDER OF PROVIDER NUMBERS

TO: ALL SERVICE PROVIDERS

All Service providers affiliated with AHFoZ are reminded to kindly renew their Provider numbers. Please complete the attached form in full and return to this office by no later than 31 March , together with:

a photocopy of your current practising certificate
Health Professions Authority (HPA) premises certificate (if applicable)
Medicines Control Authority of Zimbabwe (MCAZ) premises and persons licenses (if applicable)

Failure to renew by that date will result in the withdrawal of your Provider number as it will be assumed that the number is no longer in use. No renewal fees are being charged.

NB: AHFoZ is currently carrying out trainings on ICD10 Coding. Kindly contact us on the above details for further information.

PERSONAL DETAILS

Step 1 of 4

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*

Title
*

Initials
*

First Names

Surname
*

ID Number
*

Practicing Certificate No.
*

Expiry Date
*

Dispensing License No.
(if applicable)
*

Effective Date
*

Expiry Date

PRACTICE DETAILS
*

Provider Payee No.
*

Name of Practice/Institution
*

HPA Premises Reg. No.
*

Effective Date
*

Expiry Date
*

Dispensing License No.
(if applicable)
*

Effective Date
*

Expiry Date

CONTACT DETAILS
Postal Address*

Street Address

Address Line 2
Physical Address*

Street Address

Address Line 2
Telephone No.*
Fax No.*
Email Address*
Cell phone No.*
Skype I.D*

PROVIDER BANKING DETAILS
Bank Name*
Account No.*
Account Name*
Branch Code & Name*
DECLARATION
I declare that the information given in this form is correct and complete.

I have enclosed all relevant copies of certificates.
Signature:
Date

Provider Payee Number Renewal Form

RENEWAL REMINDER OF PROVIDER NUMBERS

PERSONAL DETAILS

Step 1 of 4

PRACTICE DETAILS

CONTACT DETAILS

PROVIDER BANKING DETAILS

DECLARATION

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