Duration of the medical camp:
From: .................................................To:.....................................................................
Location....................County .....................................Sub-County .............................
Further details of the medical camp site (include details of the specific location):
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
Name of sponsoring entity ..........................................................................................
Country of registration of sponsoring entity ..............................................................
Estimated no. of patients to be seen ...........................................................................
Services to be offered during the camp:
(i) ..................................................................................................................................
(ii) ................................................................................................................................
(iii) ...............................................................................................................................
(iv) ...............................................................................................................................
(v)..................................................................................................................................
Section 3: Requirements
Attach the following documents, to this application form, in the prescribed order:
1. Copies of up-to-date licenses of ALL medical/dental practitioners involved in
the camp;
2. Copies of up-to-date licenses of ALL other health personnel involved in the
camp;
3. List of ALL non-medical/dental personnel involved in the camp;
4. Letter of authorization from the County Government or relevant Authority;
5. List of ALL Medical Equipment;
6. Referral Policy;
7. Waste management and disposal policy; and
8. Medical Indemnity Cover.
9. Proof of payment of the application fees and credentialing fees
(a) Application fees KSh. 5,000.00
(b) Credentialing fees as per the following catergories
(i) Category A—KSh.100,000.00
(ii) Category B—KSh.50,000.00
(iii) Category C—KSh.20,000.00
(iv) Category D—KSh.10,000.00
(v) Category E – Free