Professional Documents
Culture Documents
Name of Hospital
Complete Address
:
:
:
:
Classification:
Ownership
[ ] Government
[ ] Private
Function
[ ] General
[ ] Special
Status of Application
: [ ] Initial
Service Capability
[ ] Level 1
[ ] Level 2
[ ] Level 3
[ ] Level 4
[ ] Renewal
License No. ___________________________
Date Issued ___________________________
Expiry Date____________________________
Page 1 of 5
For INITIAL or RENEWAL, please tick ( ) the appropriate boxes under column B or C and provide necessary documents.
Items shaded are not required. However, if there are changes in information upon RENEWAL, please tick ( ) the
appropriate boxes under column C and provide necessary documents.
A
Documents
B
Initial
Application
C
Renewal
Application
Submit
changes only
3. Pharmacy
3.1.
List of Personnel (use ANNEX A)
3.2.
Photocopies of the following:
3.2.1. Proof of qualification of pharmacist
3.2.1.1. PRC ID
3.2.1.2. Certificate of Training in Licensing of Drug
Establishments and Outlets
3.3.
3.4.
4. Radiology
4.1.
List of Diagnostic Radiology and Radiation Oncology Services by
Category (use ANNEX E)
4.2.
List of Personnel for Diagnostic Radiology and Radiation Oncology
Services (use ANNEX F)
4.3.
For diagnostic radiology services, photocopies of the following:
4.3.1. Proof of qualification of radiologist and radiologic/ x-ray
technologist
4.3.1.1. PRC ID
4.3.1.2. Specialty Board Certificate (for radiologist)
4.3.1.3. Certificate of Training
4.4.
For radiation oncology services, photocopies of the following:
4.4.1. Proof of qualification of radiation oncologist/ medical
physicist/ radiotherapy technologist
Page 2 of 5
A
Documents
B
Initial
Application
C
Renewal
Application
4.4.1.1.
4.5.
4.6.
4.7.
4.8.
4.9.
4.10.
4.11.
4.12.
A
Documents
7.4.
7.5.
7.6.
7.7.
B
Initial
Application
C
Renewal
Application
10.3.
10.4.
10.5.
10.6.
10.7.
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)
Documentation of Chain of Custody
Quality Control Program (for screening laboratory) OR
Certification for Quality Standard System by a DOH recognized certifying
body (for confirmatory laboratory)
Certificate of Proficiency/ Proficiency Testing Result
Procedure Manual
12.2.
A
Documents
12.3.
B
Initial
Application
C
Renewal
Application
Page 5 of 5
ANNEX M
Acknowledgement
Republic of the Philippines
)
City/Municipality of _______________ ) S. S.
I, ____________________________, ____________________________, of legal age,
Name
Designation
Home Address
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_______