The form below will help GHA understand your current needs and how we can better support your business objectives. GHA accreditation and advisory services are relevant to organizational programs often labeled as Global Patient Services, International Patient Services, Medical Tourism, Dental Tourism, Wellness travel, Medical Destinations Program or Medical Travel Services.

Should you have any questions, please contact Mr. Bill Cook at wcook@ghaccreditation.com.

1. Please enter the information for the organization and the individual who should be contacted regarding the information submitted in this form.

Name of Organization

Primary Contact Name:

Primary Contact Title
(position in the organization):

Primary Contact
Email Address:

Primary Contact
Phone Number:

City/Town:

State/Province:

Zip/Postal Code:

Country:

2. Please enter the following information:

Main Website Address:

3. What type of organization?

In-patient hospital

Out-patient facility (e.g. ambulatory surgical center, dental clinic, etc...)

Other (please specify)
4. Overall organizational & operational structure

Single Facility

Multiple Facilities (System)

Multiple Facilities (Network)

Academic Medical Center

Other

Other (please explain)

5. Is your organization accredited by a recognized national or international accreditation agency, such as those recognized by ISQua or other regulatory and professional bodies? Some examples of national accrediting bodies include India's National Accreditation Board for Hospitals and Healthcare Providers (NABH) or Thailand's HA Accreditation. International accrediting bodies include Joint Commission International (JCI) and Accreditation Canada.

Yes

No

Other (please specify)6. What clinical services do you offer?

Adult ICU

Hematology

Neonatal ICU

Allergy/Immunology

Hepatology

OB/GYN

Anesthesiology

Infection Diseases

Pathology

Emergency

Internal Medicine

Pediatrics

Cardiology

Nutrition and Diabetics

Pediatric ICU

Dental Services

Reproductive Heath

Pharmacy

Dermatology

Occupational Therapy

Physical Rehabilitation

Diagnostic Radiology

Oncology

Psychiatry

ENT

Orthopedics

Pulmonology/Pneumology

Endocrinology

Ophthalmology

Radiation Oncology

Family Medicine

Other specialty ICU services

Radiology

Gastroenterology

Nephrology

Rheumatology

Geriatrics

Nephrology

Urology

Other (please specify)7. Do you currently receive medical travel or international patients?

Yes

No8. We are also intereste in:

Training on the GHA standards

Training on the medical travel best practices

Gap assessment or "mock survey"

Assistance developing a medical travel program or international patient department

Certified Medical Tourism Professional (CMTP)

Other (please specify)9. Please provide any additional information about your organization that you think is relevant to this application.10. Please list 3 dates that would be options for GHA services.

Date 1

Date 2

Date 3

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COVID-19 Guidelines
for Medical Travel Programs

Learn about the COVID-19 Guidelines for Medical Travel Programs.

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Orthopedic
Rehabilitation
Center

The Global Healthcare Accreditation (GHA) Program is an independent accrediting body that seeks to improve the patient experience and excellence of care received by patients who travel for their medical care and treatment, whether within their own country or internationally.

Tel: 00 123 123 1234 email: info@alphamed.com

HOTEL Needs Assessment

Global Healthcare Accreditation Needs Assessment

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