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HPCSA Number: Identity Number: Nominated Society / Prof. body Name: Surname: Hospital Facility: Hospital Group: Partnership/Group Practice Number(if applicable): Individual Practice Numbers of allparticipating Clinicians: VAT number: Accounts submitted using:Individual / Partnership/Group Practice Number: Category of related I. H. P. (2,3,4,5): Physical address: Street: Suburb: Town: Postal code: Postal address Business phone number: District: Cell phone number: E-mail:
