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M u 64 (Ban hnh km theo Quy t nh s 617/Q-UBND-HC
ngy 28 thng 6 nm 2013 caCh tchUBND t nh ng Thp)
UBND T NH NG THP S Y T
CNG HO X HI CH NGHA VIT NAM c lp- T do- Hnh phc
...... ............... .... , ngy....... thng... .....nm
20....
BIN BN THM NH C S DCH VY
T.......................................
I. THNG TIN V C S C THM NH 1.Tn c s khm bnh, cha bnh: 2. a ch:
3. in thoi:. Email (nu c): 4. Fax: II. THNH PHN THAM GIA THM NH A.
Thnh phn on thm nh
+ S Y t: 1.
.......................................................; Ch c
v:........................................... 2.
.......................................................; Ch c
v:...........................................3.
.......................................................; Ch c
v:........................................... 4.
.......................................................; Ch c
v:...........................................
+ Phng Y t : 1
.......................................................; Ch c
v:............................................ 2. .
......................................................; Ch c
v:............................................
B. i din ca c s c thm nh: 1. ..2.
III. CN C PHP L THM NH - Cn c Lut Khm bnh, cha bnh ngy 23 thng
11 nm 2009; - Cn c Ngh nh s 87/2011/N-CP ngy 27 thng 9 nm 2011 quy
nhchi ti t thi hnh m ts iu ca Lut khm bnh, cha bnh; - Cn c Thng t
s41/2011/TT- BYT ngy 14/11/2011 c a B Y t hng
d n cp chng ch hnh ngh i vi ngi hnh ngh v cp giy php hotng i vi
c s khm bnh, cha bnh.
- Theo n ngh cp giy php hot ng khm bnh, cha bnh ca ng(B): IV. NI
DUNG THM NH1. H s php l: ( Lit k y cc giy t c lin quan)
...
Nhn xt:..........
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M u 64 (Ban hnh km theo Quy t nh s 617/Q-UBND-HC
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2. T chc b my: C s khm bnh, cha bnh c qui
m........................c t chc nh sau
a. B phn qun l:- Ban gim c Ch c s - Cc phng: ...
b. B phn chuyn mn:- .......- ...
Nhn xt:.....3. T chc, nhn s:
a. C s c tng s nhn vin: ...... ngi; trong nhn vin lm c ng
vicchuyn mn: ....... ngi. TT Ch c danh Phng ti p nhn Phng k thut
Tng s 123
Tng s
TT Ch c danh Hp ng lm vi c
thng xuyn (ton th igian)
Hp ng lm vi ckhng thng xuyn(mt phn thi gian)
Tng s
12
Tng s b. Ngi chu trch nhim chuyn mn k thut phi c ch ng ch hnh
ngh
v thc hin vic khm bnh, cha bnh trong phm vi phn cngt Khng t
4. C s vt cht:- Din tch chungm2, (di.m. x r ngm.......); - K t
cu nh
................................................................-
Tr n nh chng bi t Khng t - a im c nh t Khng t - nh sng t Khng t -
Tch bi t vi ni sinh hot gia nh t Khng t - C s ng k .phng, trong
:
+ Phng .+ Phng ..- C s c bin hiu ng qui nh(tn c s, a ch, gi l m
vic, ngi ph
trch, in thoi..) t Khng t - C ni bnh nhn ng i ch t Khng t - C
bn, gh o huy t p, o nhi t cho b nh nhn
t Khng t - C gi ng bnh bnh nhn ngh ng i hoc tim thu c hoc r a
vt
th ng, thay b ng (Ch c s khng c truyn dch) t Khng t
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M u 64 (Ban hnh km theo Quy t nh s 617/Q-UBND-HC
ngy 28 thng 6 nm 2013 caCh tchUBND t nh ng Thp)
5. in, nc,vsinh, v sinh mi trng, phng chy cha chy:- H thng in, h
thng nc m bo t Khng t - m bo cc iu kin x l cht thi v v sinh mi
trng
t Khng t - H thng PCCC t Khng t - Phng v sinh t Khng t
6. Trang thit b dng c y t: - Danh m c trang thit b y t (nh k m
bin b n) t Khng t - S theo di, qu n lqunl bnh nhn t Khng t - T lu n
thuc cabc s t Khng t - H p thu c chng chong t Khng t - C y d ngc
tim, chch, thay b ng, np cho bnh nhn.
t Khng t - C d ngc tit khu n d ngc y t t Khng t
7. Phm vi hnh ngh c th:
..8. Quy trnh k thut
C b ng quy tr nh k thut y t Khng t 9. Gi dch v: C nim y t bng
gid ch v t Khng t V. KT LUN V KIN NGH
1. Kt lun:..
2. Kin ngh: ......
3. kinkhngng vi kt lun v kin ngh ca on thm nh (nuc)
......
Bin b n kt thc lc gi pht, cng ngy.TRNG ON PHNG Y T TH K
I DIN C S C THM NH
