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PAHMOC

PHYSICIAN APPLICATION AND INFORMATON SHEET


    A. PERSONAL DATA














    B. PROFESSIONAL DATA








    C. HOSPITAL/CLINIC AFFILIATION (WITH REGULAR CLINIC SCHEDULE)

    D. OTHER HOSPITAL/CLINIC (VISITING)

    E. OTHER FIELD OF PRACTICE (Telemedicine/Video Consult/Home Visits)







    I hereby agree to be affiliated to all hospitals and clinics written in this form.

    “I certify that all my information written above are TRUE and CORRECT” “and I agree to update PAHMOC for any changes in my information.”

    I give my consent to the PAHMOC to gather, use, share, store, and dispose of my personal and sensitive information in keeping with the Data Privacy Act of 2012.



    APPROVING OFFICERS (NAME AND SIGNATURE)





    NOTE: ATTACHED ARE THE FOLLOWING DOCUMENTARY REQUIREMENTS