Professional Documents
Culture Documents
Name of Hospital Complete Address No. & Street City/ Municipality Region Telephone and/or Fax Number Name of Owner Chief of Hospital/Medical Director Chairman of the Board (If Corporation) Authorized Bed Capacity Classification: Ownership [ ] Government [ ] Private : : : : : : : Function [ ] General [ ] Special Service Capability [ ] Level 1 [ ] Level 2 [ ] Level 3 [ ] Level 4
Ancillary and Other Clinical Services: [ ] Clinical Laboratory [ ] Primary [ ] Secondary [ ] Tertiary [ ] Blood Bank [ ] Blood Collection Unit [ ] Blood Station [ ] HIV Testing Laboratory [ ] Laboratory for Drinking Water Analysis [ ] Drug Testing Laboratory [ ] Screening [ ] Confirmatory [ ] Pharmacy No. of satellite, please specify [ ] Dialysis Clinic [ ] Ambulatory Surgical Clinic [ ] Birthing Home or CEmOC [ ] Others, please specify
[ ] Diagnostic X-ray Services [ ] Level 1 [ ] Level 2 [ ] Level 3 [ ] Specialized Diagnostic X-ray Services [ ] Computed Tomography [ ] Mammography [ ] Digital Subtraction Angiography [ ] Cardiac Catheterization [ ] Angiocardiography [ ] Percutaneous Transluminal Angioplasties [ ] Bone Densitometry [ ] Tumor Localization and Simulation [ ] Others, please specify [ ] Dental [ ] Panoramic [ ] Cephalometric [ ] Radiation Oncology [ ] Conventional Radiation Therapy [ ] Stereotactic Radiosurgery (SRS) [ ] Intensity Modulated Radiation Therapy (IMRT) [ ] 3D Conformal Radiation Therapy [ ] Total Body Irradiation (TBI) [ ] Others, please specify [ ] Renewal License No._____________________________ Date Issued_____________________________ Expiry Date_____________________________
Status of Application
: [ ] Initial
Page 1 of 5
A Documents
B Initial Application
C Renewal Application
A Documents radiotherapy technologist 4.4.1.1. PRC ID (for radiation oncologist and radiotherapy technologist) 4.4.1.2. Specialty Board Certificate (for radiation oncologist) 4.4.1.3. Masters Degree in Medical Physics (for medical physicist) 4.4.1.4. Certificate of Training 4.5. List of X-ray Machines (use ANNEX G) 4.6. Acceptance/Performance Test Result for Computed Tomography and Mammography x-ray machines 4.7. Photocopy of official receipt from PNRI for new film badge subscription for one year 4.8. Photocopy of film badge personal dose evaluation reports within the validity period of the hospital license 4.9. Certificate of compliance with pre-operational requirements for medical linear accelerator facility 4.10. Facility report on the installation and commissioning of the equipment duly signed by the facilitys qualified medical physicist and the technical representative of the equipment manufacturer/supplier 4.11. Conformance testing report of the BHDT medical physics team on the x-ray units in the medical linear accelerator facility 4.12. Quality audit report of the BHDT health physics team on the medical linear accelerator facility
B Initial Application
C Renewal Application
A Documents
B Initial Application
C Renewal Application
8. HIV Testing Laboratory 8.1. List of Personnel (use ANNEX A) 8.2. Photocopies of the following: 8.2.1. Proof of qualification of medical technologist 8.2.1.1. PRC ID 8.2.1.2. Certificate of Training 8.3. List of Testing Materials (use ANNEX I) 9. Laboratory for Drinking Water Analysis 9.1. List of Personnel (use ANNEX A) 9.2. Photocopies of the following: 9.2.1. Proof of qualification of analyst 9.2.1.1. PRC ID
9.2.1.2. PSP Certificate, if applicable
9.2.1.3. Certificate of Training 9.3. List of Parameters for Each Service Capability (use ANNEX J 9.4. List of Equipment, Reagent, Laboratory Ware and Materials for Specific Test (use ANNEX K) 9.5. Quality Manual for Drinking Water Analysis 10. Drug Testing Laboratory 10.1. List of Personnel (use ANNEX A) 10.2. Photocopies of the following:
10.2.1. Proof of qualification of head of the laboratory, analyst and authorized specimen collector
10.3.
10.2.1.1. PRC ID 10.2.1.2. PAM Registration, if applicable 10.2.1.3. Certificate of Training List of Equipment/ Instrument (use ANNEX B)
10.4. Documentation of Chain of Custody 10.5. Quality Control Program (for screening laboratory) OR Certification for Quality Standard System by a DOH recognized certifying body (for confirmatory laboratory) 10.6. Certificate of Proficiency/ Proficiency Testing Result 10.7. Procedure Manual
11. Ambulatory Surgical Clinic 11.1. List of Personnel (use ANNEX A) 11.2. Photocopies of the following:
11.2.1. Proof of qualification
11.2.1.1. PRC ID
11.2.1.2. Specialty Board Certificate
11.3.
11.4. List of Surgical Operations/ Procedures 11.5. Documented Quality Assurance Program 12. Birthing Home or Comprehensive Emergency Obstetric Care (CEmOC)
12.1.
12.2.
12.2.1.1. PRC ID
Page 4 of 5
A Documents
12.2.1.2. Specialty Board Certificate
B Initial Application
C Renewal Application
12.3.
Page 5 of 5
ANNEX M Acknowledgement Republic of the Philippines ) City/Municipality of _______________ ) S. S. I, ____________________________, ____________________________, of legal age,
Name Civil Status Designation
after having been sworn in accordance with law hereby depose and say that I am executing this affidavit to attest to the completeness and truth of the foregoing information and the attached documents and to the hospitals compliance with all standards and requirements for the Registration and Initial/ Renewal of License to Operate a Hospital as set by the Department of Health.
_____________________________
Signature
Before me, this _______ day of ______________ 2007 in the City/ Municipality of _____________________, Philippines, personally appeared the above affiant with Community Tax Certificate No. _____________________ issued on _____________________ at _____________________, known to me to be the same person/s who executed the foregoing instrument and they acknowledge to me that the same is their free act and deed. IN WITNESS WHEREOF, I have hereunto set my hands this _________day of _______________ 2007.
NOTARY PUBLIC My Commission Expires December 31, 20______ Doc. No. ___________; Page No. __________; Book No. __________; Series of 20________