Provider Data Sheet/Enrollment Form

Name of Business: *

Salutation:

First Name: *

Last Name: *

Provider Type: *

Registered entity name, if different than public trading name:

TRN: *

(e.g. 123-456-789)

Professional Registration #: *

Address 1: *

Address 2:

Parish: *

Telephone #: *

Fax #:

Email Address: *

Principal Contact: *

Registration Authority: *

Fax

You can either email the document or select the box below to indicate that you will fax the relevant documents within 24 hours. What would you like to do?

Has your licence ever been revoked or suspended?: *

Yes

If Yes for above, please provide proof of outcome, if favourable:

Fax

You can either email the document or select the box below to indicate that you will fax the relevant documents within 24 hours. What would you like to do?

Technology used at your office

Do you have a working computer?: *

Yes

Version of Windows/Mac used: *

Other:

Do you use Internet Explorer 6.0 or above?:

Yes

Internet connection: *

How would you like to receive reimbursements?: *

Electronic Funds Transfer

Cheque

Comments:

I declare that I have reviewed the above information and confirm that it is an accurate representation of the details required for the purposes of this application.: *

Agree

Note:

For healthcare professionals, EVIDENCE OF CURRENT REGISTRATION with the Medical Council, Dental Council or Pharmacy Council authorizing the applicant to practice/render services in Jamaica , IS REQUIRED.

For pharmacies, laboratories,dignostic facilities and medical centres EVIDENCE OF REGISTRATION UNDER THE COMPANIES ACT IS REQUIRED. Copies of professional degrees/diplomas including post graduate studies are required for all Principals and Senior Officers. Please supply a certified English translation for foreign language documentation.

Provider Data Sheet/Enrollment Form

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