Professional Documents
Culture Documents
Classification According to
Ownership : [ ] Government [ ] Private
A B C
Documents For Initial For Renewal
1. Notarized Application for License to Operate a Dialysis Clinic (this form)
2. Letter of Endorsement to the BHFS Director (if filed at CHD)
3. List of Personnel (use attached form)
4. Photocopies of the following:
4.1. Proof of qualification of the medical and paramedical staff
PRC ID/ PRC Board Certificate
Specialty Board Certificate of the medical staff
Certificate of Training/ Record of Work Experience
4.2. Proof of employment of the medical, paramedical and administrative staff
5. List of Equipment/ Instrument (use attached form)
6. Duly accomplished Assessment Tool (use attached form)
7. Location Map for the dialysis clinic building
8. Photographs of the exterior and interior of the dialysis clinic
9. Photocopy of DOH Permit to Construct
1
The name of dialysis clinic should match the DTI/ SEC Registration and Mayors/ Business Permit.
Page 1 of 4
Form HDC-LTO-AF-2007
A B C
Documents For Initial For Renewal
10. DTI/ SEC Registration (for private dialysis clinic) OR
Issuance or Board Resolution (for government dialysis clinic)
11. Manual of Operations/ SOP of Dialysis Clinic
12. Annual Summary Report of Patients Registered to the Renal Disease Registry
(Certificate of Compliance)
13. Documented Quality Assurance Program (QAP) of Dialysis Clinic
Acknowledgement
documents required for the Registration, Licensure and Operation of Dialysis Clinics in the Philippines pursuant to
Administrative Order No. 2006-0037 Amendment to Administrative Order No. 163 s.2004: Rules and Regulations
Governing the Registration, Licensure and Operation of Dialysis Clinics in the Philippines.
_________________________
Signature
Before me, this _________day of ______________ 2007 in the City/ Municipality of ________________,
known to me to be the same person/s who executed the foregoing instrument and they acknowledge to me that the same is
IN WITNESS WHEREOF, I have hereunto set my hands this _________day of _______________ 2007.
Page 2 of 4
Form HDC-LTO-AF-2007
List of Personnel
Valid
Name Designation/ Position Highest Educational Attainment PRC Reg. No. Signature
From To
Page 3 of 4
Form HDC-LTO-AF-2007
List of Equipment2
2
Equipment should be present, functional, and owned by the dialysis clinic applying for license to operate.
Page 4 of 4