Title:* PCP Membership Update Form PCP Membership ID: PRC Nos: Last Name: First Name: Middle Name: Email Address: Cell Nos: CURRENT AREA OF ACTIVE PRACTICE: Name of Clinic/Hospital: Room No., Building: Street / Barangay : Town/City: Zip Code: Province: Region: ADDITIONAL AREA OF ACTIVE PRACTICE: Name of Clinic/Hospital: Room No., Building: Street / Barangay : Town/City: Zip Code: Province: Region: 2x2 ID Picture for new RFID purposes * * * * * * * Required fields * PHIC Health Provider No: * * * * * * HOME ADDRESS: Street: Barangay: Town/City: Zip Code: Region: * * * * * "Please upload a high resolution picture (NOT BLURRED)" "Note: You will receive a confirmation via e-mail once your update has been noted to be successful." Where do you want the PCP correspondences mailed to: PRACTISING PHYSICIAN NON-PRACTISING PHYSICIAN * * PCP Chapter Affiliation: OTHER PROFESSIONAL ACTIVITIES: I am a . . . As a practising physician, please indicate which of the following is true: (Please mark all that applies to your practice) PRIVATE CLINICAL PRACTICE SOLO CLINICAL PRACTICE GROUP CLINICAL PRACTICE HOSPITAL-BASED SCHOOL-BASED INDUSTRIAL-BASED PUBLIC HEALTH I am affiliated with OUTPATIENT PRIVATE CLINIC/S RURAL HEALTH UNIT MUNICIPAL HEALTH CLINIC PRIVATE HOSPITAL/S GOVERNMENT HOSPITAL/S I am also involved in the ACADEME/FACULTY ADMINISTRATIVE FUNCTION IN GOVERNMENT BIOETHICS/MEDICAL ETHICS BUSINESS ADMINISTRATION IN HEALTH HEALTH ADVOCACY/IES HEALTH GOVERNANCE/POLICY-MAKING HEALTH INFORMATICS INDUSTRIAL SECTOR MEDICO-LEGAL PHARMACEUTICAL INDUSTRY RESEARCH With my background as a healthcare provider, I have been active in the following: RETIRED/NOT WORKING ANYMORE LOCAL GOVERNMENT ADMINISTRATIVE FUNCTIONS POLICY-MAKING/GOVERNANCE RESEARCHER PRIVATE SECTOR VOLUNTEER WORKER RESEARCHER Home Clinic Expiry Date: * Expiry Date: date selector date selector (please click the calendar icon)
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