Facility On Boarding Form For Controlled Medication Platform
Section A: Regulatory & Facility Related Details
Regulator/Authority
Select Regulator/Authority
DOH
DHA/DHCC
MOHAP/MOPA
Have eClaimLink Account?
We do not store this information, we will only use it to verify your facility.
Regulatory User Name (Shafafiya or eClaimLink)
Regulatory Password (Shafafiya or eClaimLink)
your regulatory username and password are the credentials which you use for accessing eclaimlink or shafafiya.
Register As
Single Facility
Group Facility
If you are a member of a facility group please add all facility licenses from your group in the comment section below.
Group Facility License Numbers (رقم الترخيص)
For example F0002,F0003,F0004
Facility License Number (رقم الترخيص)
Facility License Copy
facility license number must be in the exact same format issued by the regulator.
Facility Name
Facility Type
Select Facility Type
Medical Provider (Hospital/Clinic/Medical Centre)
Pharmacy
Both (If your pharmacy and hospitals share the same HIS)
Section B: Facility HIS (Health Information System) Details.
Does Facility Use HIS ?
Yes
No
Provide HIS Name
Section C: Requester Details.
Requester Name
Requester Email
Requester Contact Number