Registration Form_Medi Switch 2011 Form Medi
Registration-Form_MediSwitch-2011- Registration-Form_MediSwitch-2011
User Manual: Registration Form_MediSwitch 2011
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“Your online, real-time solution provider” Toll Free 0800 11 22 33 Tel + 264 61 250162 Fax + 264 61 250395 supportdesk@mediswitchnamibia.com Electronic Claim Submissions Registration Form USER DETAILS PRACTICE NAME : ______________________________ NAMAF PRACTICE No : ___________________________ PRACTITIONER NAME : _________________________________ nd PRACTITIONER : _________________________________ 3 PRACTITIONER rd : _________________________________ th : _________________________________ 2 4 PRACTITIONER PHYSICAL ADDRESS POSTAL ADDRESS Street : _______________________________ Street / Box : ___________________________________ Building : _______________________________ Building : ___________________________________ Suite : _______________________________ Suite : ___________________________________ Town : _______________________________ Town : ___________________________________ PRACTICE CONTACT DETAILS Contact Person : _______________________________ Cell No : _______________________________________ Tel No : ___________________________________ Fax No : _______________________________________ E-mail : ___________________________________ PRACTICE MANAGEMENT SYSTEM INFORMATION (PMA) Software Name : ________________________________________________________________________________________ Software / Account Manager / Sales Person : _____________________________________________________________ Tel No : (______) _________________________ Fax No : (______) _________________________ Cell : __________________________________ Office Use Practice Registration on MediSwitch Namibia System Source Id : _______________________________ Password : _______________________________ Comments : _______________________________________________________________________________________ _______________________________________________________________________________________ Above information is to be handled as confidential Signed by (Full Name) : Date : ______________________________________________________________________________ ________________________________________ Signature ___________________________ Please fax the Registration Form back to the following number: 061 – 250 395
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