Accreditation Form

I hope to be approved by your medical network

Name/medical authority

Academic Qualification

Specialization

Graduation Institution

Graduation date

Profession practice number

National Number

Work start time

Work end time

Weekends

Fri.

Sat.

Sun.

Address / Contact Information

Mobile

Land Phone

Fax

P.O.Box

Postal Code

City/Governorate

Area name

Street name

Building #

I, the applicant, certify that all the information contained in this application is true and accurate, and I bear full legal responsibility for any omission or provision of incorrect information or information that does not reflect reality and the resulting consequences in accordance with applicable legislation, and in accordance with the instructions of the principles of professional practice and the controls necessary for the company to deal with its clients in a fair and transparent manner. I pledge to maintain the company’s secrets in the event that I am approved within the medical network. I consent to the specialized medical insurance management company collecting, storing, and processing any personal data necessary to enter into the agreement between me and the company, and to sharing this personal data with other parties for due diligence purposes, for as long as the company deems appropriate. This personal data will be used in accordance with the company's privacy policy, which defines the scope of data use, how it is protected, and how confidentiality is ensured. You can view the privacy policy on the website www.medser.net. I also acknowledge that I have been informed of my full right to withdraw my consent without affecting the legality of any processing that occurred prior to withdrawal, by contacting the Data Protection Officer (DPO): DPO@medser.net

I have read and agree to the Privacy Policy

Accreditation Form

$0.00

Accreditation Form

Accreditation Form

Med Service

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