APPLICATION FOR LICENSE TO OPERATE

Name of Health Facility

: ANTIPAS MEDICAL SPECIALISTS HOSPITAL INC.
Address : NATIONAL HIH!A" PO#LACION
No. $ Street #ara%&ay
ANTIPAS NO'TH COTA#ATO ()
City*M+%ici,ality Pro-i%ce 'e&io%
Ty,e of Health Facility:
. / Am0+latory S+r&ical Cli%ic
Ser-ice*s: colorectal s+r&ery otolary%&olo&ic s+r&ery
&e%eral s+r&ery ,ediatric s+r&ery
o,hthalmolo&ic s+r&ery ,lastic a%d reco%str+cti-e s+r&ery
oral a%d ma1illo2facial s+r&ery re,rod+cti-e health s+r&ery
ortho,edic s+r&ery thoracic s+r&ery
+rolo&ic s+r&ery
. / #irthi%& Home
. / #lood #a%3
. / Cli%ical La0oratory
. / De%tal La0oratory
. / Dialysis Cli%ic
. / HI4 Testi%& La0oratory
. / Hos,ital
F+%ctio%: . / e%eral Le-el ( Le-el ) Le-el 5
. / S,ecialty6 S,ecify 77777777777777777777777777777777777777777777777777777777777
. / I%firmary
. / Psychiatric Care Facility
ac+te chro%ic c+stodial
Tele,ho%e No.: 89:2;)528885 Fa1 No : NOT APPLICA#LE E2mail Address: amshi8))<89=yahoo.com
Head of the Facility : D'. CH'ISTOPHE' C. EM#ALSADO6 DPAMS6 MHA
>Chief of Hos,ital ?for Hos,itals@: D'. 'OD'IO A. DAA'TE6 B'. DPAMS6 FICS6 DP#S6 FPSMS6 MHA
OC%er : ANTIPAS MEDICAL SPECIALISTS HOSPITAL6 INC.
Classificatio% Accordi%& to:
OC%ershi, : . / o-er%me%t . / Pri-ate
I%stit+tio%al Character: . / Hos,ital 0ased . / No%2hos,ital 0ased
Stat+s of A,,licatio% : . / I%itial . / 'e%eCal
Lice%se No. ()2 ()2 8;82 8(52 ()2 P
4alidity BANAA'" D DECEM#E' )8(:
A+thoriEed #ed Ca,acity ?A#C@ :
Please tic3 ?@ the a,,ro,riate 0o1es 0eloC a%d ,ro-ide %ecessary doc+me%ts. Item shaded is %ot reF+ired.
Documents Initial Renewal
(. Ac3%oCled&eme%t ?%otariEed@
2. List of Perso%%el ?+se ANNEG A@
3. List of EF+i,me%t*I%str+me%t ?+se ANNEG #@
:. List of A%cillary Ser-ices ?ANNEG C@6 if a,,lica0le
5. A,,licatio% Form ? for Medical G2ray Facility@
6. A,,licatio% Form ?for Hos,ital Pharmacy@
H. Health Facility eo&ra,hic Form ?Locatio% Ma,@
<. Photo&ra,hs of the e1terior a%d i%terior of the health facility
I. A%%+al Statistical 'e,ort ?for Hos,ital*#irthi%& Home@ 1111111111
Note: Please refer to www.bfs.!o."o#.$. A$$lication Form for oter ancillar% ser#ices
Name an! Si"nature of A$$licant Date of A$$lication
Re$ublic of te Pili$$ines
De$artment of &ealt
'(REA( OF &EALT& FACILITIES AND SER)ICES
Form2HF2LTO2A
'e-isio%: 88
89*89*)8(5
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DR. CHRISTOPHER C. EMBALSADO, DPAMS,
MHA
OCTOBER 01, 2014
ANNE* A
LIST OF PERSONNEL
Name of Health Facility: ANTIPAS MEDICAL SPECIALISTS HOSPITAL6 INC
Address of Health Facility : NATIONAL HIH!A"6 PO#LACION6 ANTIPAS6 NO'TH COTA#ATO
Fill up all items by writing down the answer and/or putting a check on the appropriate boxes.
NAME POSITION
DEPARTMENT
(if hospital)
PRC No.
STATUS
SIGNATURE
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Ase additio%al sheets Che% %ecessary
Pre,ared 0y: 7777777777777777777777777777777777777777777
Form2HF2LTO2A
'e-isio%:88
89*89*)8(5
Pa&e ) of ;



ANNE* '
LIST OF E+(IP,ENT-INSTR(,ENT
Name of Health Facility:
Address of Health Facility :
Fill up all items by writing down the answer and/or putting a check on the appropriate boxes.
ITE,
DATE
AC+(IRED
+T.
CONDITION
RE,AR/S
NeC Ser-icea0l
e
Ase additio%al sheets Che% %ecessary.
Pre,ared 0y: 7777777777777777777777777777777777777777777777777

ANNE* C
LIST OF SER)ICES IN A &OSPITAL
0ENERAL LE)EL 1 LE)EL 2 LE)EL 3
Clinical
Ser#ices
an!
Facilities for
In4Patients
. / Co%s+lti%& S,ecialists i%: . / Co%s+lti%& S,ecialists i%: . / Co%s+lti%& S,ecialists i%:
. / Medici%e . / Medici%e . / Medici%e
. / Pediatrics . / Pediatrics . / Pediatrics
. / O#2"NE . / O#2"NE . / O#2"NE
. / Surgery . / S+r&ery . / S+r&ery
. / Emer&e%cy a%d O+t2,atie%t Ser-ices . / Emer&e%cy a%d O+t2,atie%t Ser-ices . / Emer&e%cy a%d O+t2,atie%t Ser-ices
. / Isolation Facilities . / Isolatio% Facilities . / Isolatio% Facilities
. / Surgical/Maternity Facilities . / S+r&ical*Mater%ity Facilities . / S+r&ical*Mater%ity Ser-ices
. / Dental Clinic . / De%tal Cli%ic . / De%tal Cli%ic
. / De,artme%taliEed Cli%ical Ser-ices . / De,artme%taliEed Cli%ical Ser-ices
. / Respiratory nit . / 'es,iratory A%it
. / e%eral ICA . / e%eral ICA
. / !igh Risk "regnancy nit . / Hi&h 'is3 Pre&%a%cy A%it
. / NICA . / NICA



. / Teachi%&*Trai%i%& C* Accredited
'eside%cy Trai%i%& Pro&ram i%:
. / Medici%e
. / Pediatrics
. / O#2"NE
. / S+r&ery
. / Physical Medici%e a%d 'eha0ilitatio%
A%it
. / #mbulatory Surgical Clinic
. / Dialysis Clinic
Ancillar%
Ser#ices
. / Secondary Clinical $aboratory . / Tertiary Cli%ical La0oratory
. / Tertiary La0oratory w/
histopathology
. / %lood Station . / #lood Statio% . / #lood #a%3
. / &
st
$e'el ()ray . / *
nd
$e'el ()ray w/ mobile unit . / 5
rd
Le-el G2ray
. / "harmacy . / Pharmacy . / Pharmacy
Oter
Ancillar%
Ser#ices
5 6 S$eciali7e! Dia"nostic *4ra% Ser#ices 5 6 Ra!iation Oncolo"% . / HI4 Testi%& La0oratory
. / Com,+ted Tomo&ra,hy . / Co%-e%tio%al 'adiatio% Thera,y . / La0oratory for Dri%3i%& !ater A%alysis
. / Lithotri,sy . / Stereotactic 'adios+r&ery ?S'S@ . / Dr+& Testi%& La0oratory
. / Cardiac CatheteriEatio%
. / Mammo&ra,hy
. / I%te%sity Mod+lated 'adiatio%
Thera,y ?IM'T@
. / others6 s,ecify
. / #o%e De%sitometry
. / Di&ital S+0tractio% A%&io&ra,hy
. / 5D Co%formal 'adiatio% Thera,y
. / Total #ody Irradiatio% ?T#I@
. / Perc+ta%eo+s Tra%sl+mi%al A%&io,lasty
5 6 T+mor LocaliEatio% a%d Sim+latio%

Form2HF2LTO2A
'e-isio%:88
89*89*)8(5
Pa&e 5 of ;
Form2HF2LTO2A
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Pa&e : of ;
Ac8nowle!"ement
'EPA#LIC OF THE PHILIPPINES @
CIT"* MANICIPALIT" OF JIDAPA!AN CIT " @S.S.
I6 D'. 'OD'IO A. DAA'TE6 B'6 MA''IED 6 of le&al a&e6 6 a reside%t of
+ame Ci'il Status #ge
M ANONOL6 JIDAPA!AN CIT" 6 after ha-i%& 0ee% sCor% i% accorda%ce Cith laC
#ddress
here0y de,ose a%d say that I am e1ec+ti%& this affida-it to attest to the com,lete%ess a%d tr+th of the
fore&oi%& i%formatio% a%d the attached doc+me%ts reF+ired for the lice%se to o,erate ,+rs+a%t to e1isti%&
r+les a%d re&+latio%s.
Si&%at+re
#efore me6 this 777777 day of 7777777777777777777777777777 )8(5 i% the City*M+%ici,ality of
77777777777777777777777776 Phili,,i%es6 ,erso%ally a,,eared the a0o-e affia%t Cith Comm+%ity
Ta1 Certificate No. 777777777777777777 iss+ed o% 77777777777777777777777 at 77777777777777776
J%oC% to me to 0e the same ,erso%*s Cho e1ec+ted the fore&oi%& i%str+me%t a%d they ac3%oCled&e to me
that the same is their free act a%d deed.
,wner Community -ax +umber Issued at/ on
3%oC% to me to 0e the same ,erso%*s Cho e1ec+ted the fore&oi%& i%str+me%t a%d they ac3%oCled&e to me
that the same is their free act a%d deed.
IN !ITNESS !HE'EOF6 I ha-e here+%to set my ha%ds this 7777day of 77777777777777776 )8777
Doc No. 77777777 NOTA'" PA#LIC
Pa&e No. 77777777 My Commissio% E1,ires
#oo3 No. 77777777 Dec. 5(6 )8 7777
Series of 77777777
Form2HF2LTO2A
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