Registration Form_Medi Switch 2011 Form Medi
Registration-Form_MediSwitch-2011- Registration-Form_MediSwitch-2011
User Manual: Registration Form_MediSwitch 2011
Open the PDF directly: View PDF 
.
Page Count: 1
- USER DETAILS
- PRACTICE MANAGEMENT SYSTEM INFORMATION (PMA)
- Office Use
- Practice Registration on MediSwitch Namibia System
- Signed by (Full Name) : ______________________________________________________________________________
- Date : ________________________________________ Signature ___________________________
Electronic Claim Submissions
Registration Form
USER DETAILS
PRACTICE NAME : ______________________________ PRACTITIONER NAME : _________________________________
NAMAF PRACTICE No : ___________________________ 2nd PRACTITIONER : _________________________________
3rd PRACTITIONER : _________________________________
4th 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 : (______) _________________________ Cell : __________________________________
Fax No : (______) _________________________
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
“Your online, real-time solution provider”
Toll Free 0800 11 22 33
Tel + 264 61 250162
Fax + 264 61 250395
supportdesk@mediswitchnamibia.com
