Mu 65

(Ban hnh km theo Quyt nh s 617/Q-UBND-HC

ngy 28 thng 6 nm 2013 ca Ch tch UBND tnh ng Thp)

UBND TNH 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 V LM RNG GI.......................................
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. .......................................................; Chc v:...........................................
2. .......................................................; Chc v:...........................................
3. .......................................................; Chc v:...........................................
4. .......................................................; Chc v:...........................................
+ Phng Y t:
1 .......................................................; Chc v:............................................
2. .......................................................; Chc 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 nh
chi tit thi hnh mt s iu ca Lut khm bnh, cha bnh;
- Cn c Thng t s 41/2011/TT- BYT ngy 14/11/2011 ca B Y t hng
dn cp chng ch hnh ngh i vi ngi hnh ngh v cp giy php hot
ng 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 NH
1. H s php l: (Lit k y cc giy t c lin quan)

...

Nhn xt: ..........

Mu 65
(Ban hnh km theo Quyt nh s 617/Q-UBND-HC
ngy 28 thng 6 nm 2013 ca Ch tch UBND tnh ng Thp)

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:
C s c tng s nhn vin: ...... ngi; trong nhn vin lm cng vic
chuyn mn: ....... ngi.
TT
1
2
3

Chc danh

Phng tip nhn

Phng khm

Phng k thut

Tng s
TT

Chc danh

Hp ng lm vic
thng xuyn (ton thi
gian)

Hp ng lm vic
khng thng xuyn
(mt phn thi gian)

Tng s

1
2
Tng s

4. C s vt cht:
- Din tch chungm2, (di.m. x rngm.......);
- Kt cu nh ................................................................
- Trn nh chng bi
t Khng t
- a im c nh
t Khng t
- nh sng
t Khng t
- Tch bit 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 lm vic, ngi ph
trch, in thoi..)
t Khng t
- C s c k hp ng vi c s lm rng gi khc C Khng c
Nu c th ghi r tn c s, a ch c s..

Thi hn hp ng, Phng thc hp ng.

.
4.1. Phng khm v lp rng, hm gi:
- C ni tip n khch hng
t Khng t
- C ni khch hng ngi ch
t Khng t
2
- C din tch t nht 10m
t Khng t

Mu 65
(Ban hnh km theo Quyt nh s 617/Q-UBND-HC
ngy 28 thng 6 nm 2013 ca Ch tch UBND tnh ng Thp)

- C gh nha v dng c lm rng gi, hm gi

t Khng t
4.2. Phng lm rng gi, hm gi
- C din tch t nht 10m 2
t Khng t
5. in, nc, v sinh, 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 mc trang thit b y t (nh km bin bn)
t Khng t
- S qun l rng gi, hm gi, vt liu ho cht lm rng gi, hm gi (ghi r
ngun gc sn xut, ngy nhp, s lng nhp c i chiu c th trn ho n
nhp)
t Khng t
- S theo di, qun l khch hng lp rng, hm gi
t Khng t
- Lp l lch, xy dng ni quy, quy nh vn hnh thit b, thc hin ch
bo dng thng xuyn v nh k
t Khng t
7. Phm vi hnh ngh c th:

..
8. Quy trnh k thut
C bng quy trnh k thut y
t Khng t
9. Gi dch v: C nim yt bng gi rng gi, hm gi
t Khng t
V. KT LUN V KIN NGH
1. Kt lun:
..
2. Kin ngh:
..
..
3. kin khng ng vi kt lun v kin ngh ca on thm nh (nu
c).....
..
..
Bin bn kt thc lc
gi
pht, cng ngy.
TRNG ON
PHNG Y T
TH K

I DIN C S C THM NH