New Facility Request for First Time Certification Service Request Form Facility Name* ?Please use all upper case DoH License No.* ?Use upper case with no space Region* -None- Abu Dhabi Al Ain Western Region Type of Request* -None- Initial Certificate Renewal New Facility Listing Extension Of Listing Facility Type* -None- Hospital Medical Center/Clinic Dental Center/Clinic Home Health Care Long Term Care Center Rehabilitation Center Rehabilitation Hospital Dental* -None- Yes No Self Pay activities* -None- Yes No Facility Setting* OP ER Home care Day case Inpatient Telemedicine Rehabilitation-Outpatient Long Term Care ?Note: Hold the CTRL key and click the items for multiple options E/M Guidelines used* -None- 1995 1997 Not applicable Type of Medical Records* -None- Physical Electronic Physical & Electronic Tax Registration Number* Title First Name ?Audit Representative / Focal Point of Communications Last Name* ?Audit Representative Email* Secondary Email Mobile Phone* DescriptionUpload a DoH License ?nullFile(s) size limit is 20MB. Enter the Captcha Reload