Republic of the Philippines
Department of Health
OFFICE OF THE SECRETARY
December
9, 2019
DEPARTMENT CIRCULAR
2019
DS4g
No.
-
ALL DIRECTORS OF REGIONAL OFFICES, CHIEFS OF
THE REGULATION, LICENSING AND ENFORCEMENT
DIVISION (RLED) AND REGULATORY COMPLIANCE
AND ENFORCEMENT DIVISION (RCED), REGULATORY
OFFICERS AND OTHER CONCERNED STAKEHOLDERS
TO
SUBJECT
:
Requirements for the Renewal of Application of DOH-License
to Operate of Hospitals for CY 2020
Application for the renewal of DOH-License to Operate of hospitals for CY 2020 shall
follow the licensing requirements listed in DOH-Form 1. (Please see attached document)
All applications shall be accepted and processed. However, a post-licensing monitoring
shall be conducted starting April 2020 to check for the licensing requirements, such as:
Certificate of Inclusion for Blood Service Facility, National External Quality Assessment
Scheme (NEQAS) participation for Clinical Laboratory, and validated Electronic Medical
Record System for Online Health Facility Statistical Reporting System (OHFSRS).
For strict compliance.
By Authority of the Secretary of Health:
whrour
ROLAND
ni
. DOMINGO, MD, DPBO
Health
of
ersecretary
ealth Regulation Team
Building 1, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila e Trunk Line 651-7800 local 1108, L111, 1112, 1113
Direct Line: 711-9502; 711-9503 Fax: 743-1829 @ URL: http://www.doh.gov.ph; e-mail: ftduque@doh.gov.ph
a
\
Republic of the Philippines
Department
DOH-HFSRB-QOP-01-Form1
Name
of Health
HF Address
:
Facility (HF) or Service Provider
No.
Head of the Facility/Medical Director
:
Classification
Street
Province
]
[
]
1
city[4] Mun[C] DOH-Retained [1 University
Others, Specify.
Partnership [7] Proprietorship [7] Cooperative [7] Foundation [1]
[
] Free-Standing
[
] Non Institution-based
bist.)
[]
]
Status of Application:
Region
E-mail Address:
:
:
Government Province]
Private
Corporation
Institutional Character: [
Institution-based
[
District
Barangay
According to:
Ownership:
:
City/Municipality
Fax No
Telephone No.:
Owner
&
of Health
HEALTH FACILITIES AND SERVICES REGULATORY BUREAU
Renewal
License No. __-_—~C«“alicdiity
Authorized Bed Capacity
Date Issued
Permit to Construct No. (If applicable)
Instruction: Please tick (“) the appropriate boxes below and provide necessary documents.
[
]
New
[
]
LICENSE TO OPERATE:
[ ]
Ambulatory Surgical Clinic
(1 colorectal surgery
Service/s:
]
[
]
Ss
Birthing Home
Blood Service Facility:
Clinical Laboratory
Dental Laboratory
Dialysis Clinic
HIV Testing Laboratory
Hospital
Function: [ ] General
[
[
]
[
]
[
]
]
(J
(J
[2] otolaryngologic surgery
CI
(
Blood Bank
Blood Collection Unit (Hosp-based)
Level 1[7] Level
Specialty, Specify
2(
Infirmary
Psychiatric Care Facility
Ambulance Service Provider No. of Ambulance
Level
Type
Blood Bank w/ Addt’l. Function
Blood Station (Hosp-based)
30
|
(4) Custodial
(7) Acute chronic
Unit:
.
(J pediatric surgery
surgery
(J plastic and reconstructive
([] reproductive health surgery
(J thoracic surgery
[J urologic surgery
(J general surgery
surgery
[J ophthalmologic
(J oral and maxillo-facial surgery
(] orthopedic surgery
[
(ABC)
Type
Il
CERTIFICATE OF ACCREDITATION:
[ ]
Drug Abuse Treatment and Rehabilitation Center [7] Residential
(-] Non-Residential
[ ]
Dental Clinic
[2] Private School
(LJ Occupational Establishment
[ ]
Human Stem Cell and Cell-Based or Cellular Therapy Facility
]
Kidney Transplant Unit
[ ]
Chemical
(Bacteriological
Laboratory for Drinking Water Analysis
Physical
(JJ Regular Medical Facility
[ ]
Medical Facility for Overseas Work Applicants
(J) Special Seafarer’s Med. Fac.
Special Land-based Med. Fac.
Newborn Screening Center
AUTHORITY TO OPERATE (For Free Standing)
[ ]
[ ]
Blood Collection Unit
Blood Station
CERTIFICATE OF REGISTRATION:
[
]__Special Clinical Laboratory [7] Clinical Pathology [7] Anatomy Service Capability, Specify.
{
[1
([
[1
Documents
1.
Acknowledgement
New
Renewal
(notarized)
of
2.
Proof of Ownership and Name
Heaith Facility:
2.1 DTI/SEC/CDA Registration including Articles of Incorporation/Cooperation and By-Laws
2.2 Enabling Act/ LGU Resolution (for government health facility)
3.
Application Form for Medical X-ray Facility (if applicable)
4.
Application Form for Pharmacy
(if applicable)
5. Accomplished Health Facility Self-Assessment Tool
6.
Health Facility Geographic Form (Geographic Coordinates)
Note: Please refer to www.hfsrb.doh.gov.ph.
Name
and Signature of Applicant
for other details of the requirements.
DOH-HFSRB-QOP-01
Form1
Rev:00
3/1/2019
Date of Application
Eentastsststtnerssuntssnstst
Page
:
1 of 2:
Acknowledgement
REPUBLIC OF THE PHILIPPINES
MUNICIPALITY OF
I,
—)
CITY/
)S.S.
,
:
Civil
Name
Of
legal age,
,
Status
,
resident of
a
Age
after having been sworn
in
accordance with law
Address
hereby depose and say that | am executing this affidavit to attest to the completeness and truth of the foregoing
information and the attached documents required for the establishment/operation of health facility pursuant
to existing rules and regulations. That the undersigned is aware and informed that any misrepresentation,
falsification/deception
herein can cause the denial of my application.
Signature
Before
me,
this
day
,
of
20
in
the City/Municipality of
Philippines, personally appeared the above affiant with Community
issued on
Tax Certificate No.
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.
known to
same
me
Issued at/on
Community Tax Number
Owner
to be the same person/s who executed the foregoing
instrument and they acknowledge
is their free act and deed.
IN
Doc No.
Page No.
Book No.
Series of
WITNESS WHEREOF,
|
have hereunto set my
hands
this
to me that the
,20_
day of
NOTARY PUBLIC
My Commission Expires
Dec. 31, 20
DOH-HFSRB-QOP-01 Form1
Rev:00
3/1/2019
i
of
Page
cceetetetnetstnsrtnenee
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2
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