14 Bertram Road 						 
Milton Park							Attach two certified recent 
Harare								Passport size photographs 
								
P.O.BOX A667
									AVONDALE 
									HARARE 

MEDICAL REHABILITATION PRACTITIONERS’ COUNCIL OF
 ZIMBABWE

TELEPHONE: 04-778244							Email:mrczimbabwe@gmail.com 

Health Professions Act
Chapter 27:19
ADDITION OF A PRACTITIONER TO A HEALTH INSTITUTION
(To be completed in block letters)	

1.	NAME OF HEALTH PRACTITIONER....................................................................................................................
PHYSICAL ADDRESS...........................................................................................................................................
POSTAL ADDRESS…………………………………………………………………………………………………………………………………………
CONTACT DETAILS
TELEPHONE: (Bus)………………………………… (Cell)………………………………………… (Home)…………………….................
E – MAIL ADDRESS............................................................................................................................................
SKYPE ADDRESS................................................................................................................................................

2.	DETAILS OF INSTITUTION: 

NAME OF INSTITUTION………………………………………………………………………………………………………………………………..
HPA REGISTRATION NUMBER ……………………………………………………………………………………………………………………..
(Please attach copy of certificate)
PHYSICAL ADDRESS………………………………………………………………………………………………………………………………………
POSTAL ADDRESS…………………………………………………………………………………………………………………………………………
E – MAIL ADDRESS............................................................................................................................................
SKYPE ADDRESS................................................................................................................................................
WEBSITE............................................................................................................................................................

SPECIFY HOW YOU INTEND TO OPERATE
                 ........................................................................................................……………………………………………………………..

DATE COMMENCED /TO BE COMMENCED…………………………………………………………………………………………………..

3.	NAME OF HEALTH PRACTITIONER IN CHARGE OF THE HEALTH INSTITUTION.
FULL NAMES………………………………………………………………………………………………………………………………………………..

ADDRESS……………………………………………………………………………………………………………………………………………………..
…………………………………………………………………………………………………………………………………………………………………

PROFESSIONAL QUALIFICATIONS………………………………………………… REGISTRATION NO ……………………………….
DATE OF QUALIFICATION………………………..DATE OF EXPIRY OF PRACTICING CERTIFICATE…………………………..
                NB: Please provide an official letter written and signed by the owner of the practice authorising the addition.

4.	TYPE OF INSTITUTION

[  ] HOSPITAL							[  ] CLINIC 
[  ] NURSING HOME 						[  ] CONSULTING ROOMS 

5.	DESIGNATION OF INSTITUTION 

[  ] GOVERNMENT 			[  ] MISSION 		[  ] PRIVATE 
[  ] LOCAL AUTHORITY 			[  ] MINES		[  ] RURAL 

6.	PROVINCE LOCATED 

[  ] BULAWAYO 				[  ] HARARE		[  ] MANICALAND 
[  ] MASH CENTRAL 			[  ] MASH EAST 		[  ] MASH WEST 
[  ] MASVINGO 				[  ] MAT NORTH 		[  ] MAT SOUTH 
[  ] MIDLANDS 			

ATTACH PROOF OF NOTIFICATION TO SET UP INSTITUTION FROM LOCAL AUTHORITY.

SPECIFY HOW YOU INTEND TO OPERATE ………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………..

7.	DETAILS OF OWNER OF PREMISES

FULL NAMES…………………………………………………………………………………………………………………………………………………

ADDRESS ……… …………………………………………………………………………………………………………………………………………….

…………………………………………………………………………………………………………………………………………………………………….

TELEPHONE NUMBERS……. (Bus)…………………….……… (Mobile)………………………….. (Home)…………………………

CHECK LIST – REGISTRATION OF HEALTH INSTITUTION

Name of Institution......................................................................................................................
                              ......................................................................................................................
Physical Address.........................................................................................................................
.                           ..........................................................................................................................
Practitioner in Charge..................................................................................................................
                                  ....................................................................................................................
.                                 ......................................................................................................................  
Type of services..............................................................................................................................

	Initial Application 	Resubmitted application 	Recommend for HPA Inspection 	Not recommended for HPA Inspection 	
MRPCZ Practitioner
 In-Charge’s current Practising Certificate 
					
Practitioner’s two passport size photographs 
					
Health Inspection report from the Local Authority 
					
Proof of payment of application of health institution registration fee.					

List of Equipment in place 

STATUTORY DECLARATION OF EQUIPMENT

I ……………………………………………………………………………………………………………………………Full Names.
Of …………………………………………………………………………………………………………………………….. Address.
…………………………………………………………………………………………………Occupation, make the following declaration under the Health Professions Act (Chapter 27:19).
List the equipment in your practice:
………………………………………………………………………………………………
………………………………………………………………………………………………
 ……………………………………………………………………………………………..
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………

I understand that a person who intentionally makes a false statement in a statutory declaration is guilty of an offence under the Health Professions Act (Chapter 27:19) and I believe that the statements in this declaration are true in every particular.
………………………………………………         				………………………………………………..
Applicant								Witness

REGISTRATION OF HEALTH INSTITUTIONS 
SECTION 97 OF THE ACT 
Acknowledgement of receipt of application for the registration of a Health Institution.  

Name of Applicant..........................................................................................................................................

Name of Institution.......................................................................................................................................

Address of Institution..................................................................................................................................

Fee received $.......................................				Receipt No............................................

Date............................................

In term of Section 103 of the Health Professions Act (Chapter 27:19) the Secretary General of the Health Professions Authority is hereby authorized by copy of this letter and details of your application to process the registration of your institution. 

Please note that it is illegal in terms of Section 99 of the said Act to operate a health institution without a registration certificate from the Health Professions Authority. 

REGISTRAR 

FOR OFFICE USE ONLY
THIS APPLICATION SHOULD BE ACCOMPANIED BY A NON- REFUNDALE FEE OF $450.00

I HEREBY CERTIFY THAT THE INFORMATION GIVEN ABOVE IS CORRECT.

DATE……………………………………………………………..SIGNATURE…………………………………………………………………………
FOR OFFICE USE ONLY

RECEIVED (Amount) …………………………………………..RECEIPT NO………………………………..DATE…………………………

APPROVED [  ] 					[  ] NO 

IF YES: DATE OF APPROVAL ………………………………………………………….REGISTRATION NO……………………………….

CONDITIONS……………………………………………………………………………………………………………………………………………….

…………………………………………………………………………………………………………………………………………………………………..

IF NO REASON…………………………………………………………………………………………………………………………………………….

NAME OF RESPONSIBLE OFFICER………………………………………………………………………………………………………………..

MEDICAL REHABILITATION COUNCIL’S BANK ACCOUNTS
Account Name	Account Type	Account Currency	Branch Code	Account Number	Branch Name	
MEDICAL REHABILITATION PRACTITIONERS COUNCIL	Banc ABC NOSTRO	USD	108	54187546633010	MSASA	
MEDICAL REHABILITATION PRACTITIONERS COUNCIL	Banc ABC CURRENT ACCOUNT	ZWL	108	54187545502017	MSASA	
MEDICAL REHABILITATION PRACTITIONERS COUNCIL	CABS NOSTRO	USD		1125289465	FOURTH STREET	
MEDICAL REHABILITATION PRACTITIONERS COUNCIL	CABS SAVINGS ACCOUNT	ZWL		1004389094	FOURTH STREET	
MEDICAL REHABILITATION PRACTITIONERS COUNCIL	FIRST CAPITAL SAVINGS ACCOUNT 	ZWL	2144	1037449	PEARL HOUSE