An application for approval of outside medical practice must be made in writing stating the following matters:
部外診療の承認の申請は、次に掲げる事項を記載した書面によらなければならない。
the name, current address and public office held by the physician or dentist on staff (meaning a physician or dentist on staff prescribed in Article 55-17, paragraph (1) of the Act; the same applies hereinafter), and the grade of duties to which the person belongs;
医師等職員（法第五十五条の十七第一項に規定する医師等職員をいう。以下同じ。）の氏名、現住所及びその占める官職並びにその属する職務の級
the regular working hours of the physician or dentist on staff;
医師等職員の正規の勤務時間
the place of outside medical practice and the job title there;
部外診療先及びその職名
the working hours, content of work and scheduled period of outside medical practice at the place of outside medical practice;
部外診療先における勤務時間、勤務の内容及び部外診療の予定期間
whether there is a need for the physician or dentist on staff not to work during regular working hours, and the details thereof;
医師等職員がその正規の勤務時間において、勤務しないこととなる必要の有無及びその内容
the amount of remuneration, where the physician or dentist on staff performs outside medical practice for remuneration;
医師等職員が報酬を得て、部外診療を行う場合には、その金額
the reason outside medical practice is necessary;
部外診療を必要とする理由
other matters for reference.
その他参考となる事項