Uploaded by Richard Vincent Lacorte

RAF MAGNETIC RESONANCE IMAGING FACILITY

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Republic of the Philippines
Department of Health
FOOD AND DRUG ADMINISTRATION
Filinvest Corporate City
Alabang, City of Muntinlupa
CHECKLIST OF REQUIREMENTS FOR INITIAL ISSUANCE / RENEWAL OF
A CERTIFICATE OF REGISTRATION (COR) OF A
MAGNETIC RESONANCE IMAGING FACILITY
1.
2.
Duly accomplished MRI registration form (2 copies).
License application fee (refer to the schedule of fees below). Either a photocopy of the machine validated
Land Bank of the Philippines (LBP) OnColl Payment Slip or Manager’s Check or Cashier’s Check payable to
FOOD AND DRUG ADMINISTRATION. For LBP payment, you may visit FDA website through this link
for the guidelines for payment portal: https://ww2.fda.gov.ph/index.php/issuances-2/cdrrhr-laws-and-regulationspertaining-to-all-regulated-medical-devices/cdrrhr-fda-circular/508371-fda-circular-no-2018-004.
3.
4.
5.
6.
7.
8.
9.
INITIAL
2,020.00
Photocopy of the VALID Professional Regulation Commission (PRC) license of all the radiologist/s
and radiologic technologist/s.
Photocopy of the certificate of all the radiologist/s for being a Fellow of the Philippine College of
Radiology (FPCR) or Diplomate of the Philippine Board of Radiology (DPBR).
(FOR RENEWAL APPLICATION WITH NO CHANGES ON CURRENT RADIOLOGIST/S,
THIS REQUIREMENT IS OPTIONAL)
Photocopy of the PRC board certificate of all the radiologic technologist/s.
(FOR RENEWAL APPLICATION WITH NO CHANGES ON CURRENT RADIOLOGIC
TECHNOLOGIST/S, THIS REQUIREMENT IS OPTIONAL)
Photocopy of valid notarized contract of employment of all the radiologist/s and radiologic
technologist/s. The CDRRHR recommends that the contract be valid for at least one year.
Photocopy of the business/mayor’s permit or SEC/DTI registration of the facility.
(FOR INITIAL/VARIATION APPLICATION ONLY)
Photocopy of the latest Certificate of Registration. (FOR RENEWAL APPLICATION ONLY)
Radiofrequency/Magnetic Field map. (FOR INITIAL APPLICATION ONLY)
RENEWAL
(Valid COR)
1,010.00
Schedule of Fees (per machine)
Renewal of Expired COR
1st Month
2nd Month
3rd Month
4th Month
3,110.00
3,210.00
3,310.00
3,410.00
> 4 months
4,420.00
Notes:
1. The surcharge/penalty for late filing of the renewal of LTO will be assessed pursuant to the Implementing Rules and Regulations
(Book II, Article I Section 3.A.2) of RA 9711 and to the FDA Circular No. 2011-004 as follows:
“An application for renewal of an LTO received after its date of expiration shall be subject to a surcharge or penalty equivalent
to twice the renewal licensing fee and an additional 10% per month or a fraction thereof of continuing non-submission of such
application up to a maximum of one hundred twenty (120) days. Any application for renewal of license filed thereafter shall be
considered expired and the application shall be subject to a fee equivalent to the total surcharge or penalty plus the initial filing fee
and the application shall undergo the initial filing and evaluation procedure.”
2. Pursuant to FDA Circular No. 2011-003, a Legal Research Fee (LRF) amounting to “one percent (1%) of the filing fee imposed, but
in no case lower than ten pesos” shall be collected.
3. Incomplete requirements shall not be processed.
4. For initial/renewal application, fee paid shall be forfeited when the facility fails to comply with the licensing requirements within 60
days upon proper notice from the CDRRHR.
_______________________________________________________________________________________________
Civic Drive, Filinvest City, Alabang, 1781 Muntinlupa City
Trunk Line: (632) 857 1900, Fax No. (632) 807 0751
URL: http://www.fda.gov.ph; e-mail: cdrrhr_rrd@fda.gov.ph
Republic of the Philippines
Department of Health
FOOD AND DRUG ADMINISTRATION
Filinvest Corporate City
Alabang, City of Muntinlupa
APPLICATION FORM FOR A CERTIFICATE OF REGISTRATION OF A
MAGNETIC RESONANCE IMAGING FACILITY
General Instructions: Write legibly and in BLOCK letters. Put an “x” mark on appropriate tick box. Completely fill-up
the required information and signatures. The CDRRHR will not receive and process unduly filled-up application forms.
For requirements, please refer to the attached checklist.
TYPE OF AUTHORIZATION
New application
Renewal of COR
Amendment to existing COR# _____________
Reason/s for amendment:__________________
I General Information
ACE MALOLOS DOCTORS, INC.
Name of Facility :__________________________________________________________________
CAPITOL VIEW PARK SUBD., BULIHAN, MALOLOS CITY, BULACAN 3000
Facility Address :__________________________________________________________________
__________________________________________________________________
09173043926
Contact No./s
:__________________________________________________________________
Name and Address of the Applicant, Legal Person, Company, Organization, etc.
FERDINAND MANUEL J. DACUMOS, MD
PRESIDENT & CEO
Name :_________________________________
Position/Designation :_____________________
Address : ________________________________________________________________________
CAPITOL VIEW PARK SUBD., BULIHAN, MALOLOS CITY, BULACAN 3000
acemdradiology@gmail.com
Contact No./s:_____________________________
Email Address : ______________________
09173043926
For CDRRHR use
DTN No:
__________________
Thru mail
Walk-in
Fee Paid
PHP:______________
O.R #_____________
Date Paid __________
Assessed by:
_____________
Date :_____________
II Name and qualifications of the personnel working in the MRI facility
Head of the Facility (Radiologist) :
Chief Radiologic Technologist :
JOHANNA L. DE VERA, MD
Name : _________________________________
Qualification :
FPCR
DPBR
Others: ________________
0101276 / 08-03-2024
PRC ID#/ Validity :_______________________
RICHARD VINCENT R. LACORTE, RRT
Name : ________________________________
0011191 / 08-19-2025
PRC ID#/Validity : ______________________
SIGNATURE:
Evaluated by:
_____________
Date:_____________
Status of the Facility:
________________
________________
Action taken :
SIGNATURE:
III Declaration of the veracity of information: To be signed by the legal person/owner
I hereby declare that all the information provided on the form and in support of this application
is to the best of my knowledge complete and true in every particular.
________________
________________
________________
________________
________________
________________
Checked by:
FERDINAND
MANUEL J. DACUMOS, MD
__________________________
Printed Name and Signature
PRESIDENT & CEO
Position:___________________
02-21-2024
Date: _____________________
_____________
Date:____________
Printed by:
_____________
Date:____________
Recommending
Approval:
_____________
Date:____________
Encoded by:
_____________
Date:____________
Page 1 of 2
_______________________________________________________________________________________________
Civic Drive, Filinvest City, Alabang, 1781 Muntinlupa City
Trunk Line: (632) 857 1900, Fax No. (632) 807 0751
URL: http://www.fda.gov.ph; e-mail: cdrrhr_rrd@fda.gov.ph
IV
Equipment Specifications
Model
Magnetic Field Strength
(Tesla)
System Serial No.
Location
MAGNETOM SEMPRA
1.5T
179961
MRI ROOM GROUND FLOOR
Manufacturer
SIEMENS
V
Name and qualifications of other radiologists and radiologic technologists working in the MRI facility
Name
Designation
Qualification
PRC
License
Validity
JOHANNA L. DE VERA, MD
RADIOLOGY
HEAD OF RADIOLOGY
101276
8-3-2024
JAIME LUMIQUED, MD
RADIOLOGY
OIC HEAD RADIOLOGIST
106694
3-15-2024
RADIOLOGY
CHIEF RADTECH
11191
8-19-2025
4-21-2026
RICHARD VINCENT R. LACORTE, RRT
JACQUELINE B. SANTOS, RRT
RADIOLOGY
RADTECH
9549
JULIUS ELIEZER T. DOMINGONO, RRT
RADIOLOGY
RADTECH
9101
7-4-2024
ANDRÉ IAN DANIEL A. AQUINO, RRT
RADIOLOGY
RADTECH
16597
11-24-2023
Signature
Please use separate sheet if necessary
Application Form for a Certificate of Registration of a Magnetic Resonance Imaging Facility
Page 2 of 2
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