NOT FOR SALE

REPUBLIC OF GHANA

HEALTH FACILITIES REGULATORY AGENCY

APPLICATION FOR THE LICENSING OF A FACILITY

IMPORTANT NOTICE:

No individual practitioner can be the practitioner - in- charge of more than one facility at the same time

All columns must be completed in full and all required documents as specified under section 8 below
must be presented in full with the completed form.

Disregarding these instructions and presenting an incomplete application package may lead to delays in
the application process.

Name of Facility: ……………………………………………………………………………………………………

Type of Facility (tick √)

• CHPS Compound • Health Centre • General Clinic

• ENT Clinic • Dental Clinic • Eye Clinic

• Nursing Home • Maternity Home • Physiotherapy Clinic

• Primary Hospital • Secondary Hospital • Tertiary Hospital

• Quaternary • Diagnostic Centre • Imaging Centre

• Medical Laboratory • Optometry Centre • Occupational Health Clinic

• Dietetic Centre • Optical Centre

Others
Specify:……………………………………………………………………………………………………

Type of Ownership (tick √)

Government Quasi-Government Private NGO

Faith-Based Others……………………………………………………

Date established (if an existing facility): ........................................................

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Proposed Business hours

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Public holidays Yes No

1.0 FACILITY DATA

Name of facility:

Postal Address:

Location Address: Digital Address (GHPOST-GPS):

House Number:

Town/City: District:

Landmark: Region:

Landline Phone Number(s) (OPD):

Telephone Number(s):

E-mail Address (es):

Website:

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2.0 PERSONAL DATA

2.1 OWNER/LEGAL ENTITY

Surname/ Surname of lead person for companies:

Other names: Title:

Nationality*: Professional status:

Location/House Number:

Address:

Town: District:

Region: Phone Number:

E-mail:

Website:

2.2 PRACTITIONER- IN- CHARGE

Surname:

Other names: Title:

Professional status: Nationality* :

Location/House Number:

Address:

Town: District:

Region:

Phone Number:

E – Mail Address:
Area of specialty:
Professional PIN (MDC/NMC/AHPC/PC/ETC):

*FOR NON-GHANAIAN APPLICANTS PLEASE COMPLETE PAGE 5 AS WELL

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2.3 ADDITIONAL DETAILS FOR ADDITIONAL STAFF IN SENIOR POSITION (OPTIONAL)

Area of Specialty:
Surname:
Other names: Title:
Status/Position: Nationality* :
Location/House Number:
Address:
Town: District:
Region:
Phone Number:
E – Mail Address:

3.0 NUMBER OF EMPLOYEES

3.1 NUMBER AND TYPE OF NON-HEALTH PROFESSIONAL EMPLOYEES

Cleaners

Other (specify type and number):

Other (specify type and number):

Other (specify type and number):

Use a separate sheet if required

3.2 NUMBER AND TYPE OF HEALTH PROFESSIONAL EMPLOYEES

Specify type and number:

Other (specify type and number):

Other (specify type and number):

Other (specify type and number):

Other (specify type and number):

*FOR NON-GHANAIAN APPLICANTS PLEASE COMPLETE PAGE 5 AS WELL

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3.3 NUMBER AND TYPE OF ALLIED HEALTH PROFESSIONAL EMPLOYEES
Radiographer: ……………………………………………………………………….

Medical Laboratory Scientist: …………………….………………………………..

Physiotherapist: ………………….…………………………………………………

Optometrist: …….......………………………………………………………………

Optician: …………………………………………………………………………….

Dietician: ……………………………………………………………………………

Other (specify type and number): …….......…………………………………………

Other (specify type and number): ……………………………………………………

3.4 FOR NON –GHANAIAN APPLICANTS

Nationality:
Immigration status: Tick as appropriate
Residence Permit (Photocopies to be attached? Working Permit (Photocopies to be attached)
Date of Issue: Date of Expiry
Name of Professional body: PIN
Existence of Ghanaian Partnerships: Yes No
Details of Partnership (Name, Role, Position Etc.):

Evidence of Professional Practice in Ghana (for a period not less than one year)

Name of Facility:
Location of Facility:
Duration:
Facility Contact Details:
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 4.0 DATA ON PROFESSIONAL STAFF

No. Profession Name (surname first) Specialty Year of Year of Professional Name of Employment
Qualification Reg. with registration Accrediting designation
Professional number Professional (part time or
Body body full time)

ADDITIONAL INFORMATION CAN BE PROVIDED ON A SEPARATE SHEET TO BE ATTACHED TO THE FORM

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 5.0 TYPES OF SERVICES

5.1 LIST OF TYPES OF SERVICES TO BE RENDERED

SERIAL TYPE OF SERVICE

NUMBER

ADDITIONAL INFORMATION CAN BE PROVIDED ON A SEPARATE SHEET TO BE ATTACHED TO THE FORM

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 5.2 LIST OF TYPES OF SERVICES TO BE RENDERED (ALLIED HEALTH ONLY)

(a) General Services

(i) Pathology (ii) Radiology & Other Imaging

Services

Haematology X-Ray

Biochemistry Dental X-Ray

Microbiology OPG

Immunology

Others (Specify) Others (Specify)

Others (Specify) Others (Specify)

Others (Specify) Others (Specify)

(b) Specialized Services

Onco Pathology MRI

Transfusion Medicine CT

Transplant Pathology Mammography

Bone Densitometry USG / Colour Doppler

Others (Specify) Others (Specify)

Others (Specify) Others (Specify)

Others (Specify) Others (Specify)

ADDITIONAL INFORMATION CAN BE PROVIDED ON A SEPARATE SHEET TO BE ATTACHED TO THE FORM

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6.0 LIST OF EQUIPMENT IN THE PRACTICE WITH THEIR TECHNICAL SPECIFICATIONS.

SEQUENCE INVENTORY TYPE OF MANUFACTURER MODEL SERIAL YEAR QUANTITY LOCATION FUNCTIONAL
NO. NO EQUIPMENT NO. MANUFACTURED STATUS

ADDITIONAL INFORMATION CAN BE PROVIDED ON A SEPARATE SHEET TO BE ATTACHED TO THE FORM

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 NOTE:

False information given on this form is an offence and is punishable by Act 829, section 23.

By signing this declaration, you are agreeing that you are aware of all implications for any false
declaration on this application.

OWNER (NAME)……………………………………………………………………………

Signed …………………………………………. Date ………………….……….……….

NOTE: You are informed that HeFRA must be notified at least SIXTY (60) DAYS prior to resignation of
Practitioner-in-Charge (PIC) or termination by employer.
i. Failure to notify HeFRA by Practitioner-in-Charge (PIC) will be reported as ethical breach
to the appropriate Professional Body
ii. Any facility which fails to notify HeFRA before the termination will lead to withdrawal of
licence.

PRACTITIONER IN CHARGE (NAME) ……………………………..…………………..

Signed ………………………………………….. Date …………………………………….

Send completed form and enclosures by post or in person to:

The Registrar
Health Facilities Regulatory Agency
1st Floor Old Ministry of Health Building
Ministries-Accra. (Telephone: 0302 – 900 995)

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