Republic of the Philippines

Department of Health
HEALTH FACILITIES AND SERVICES REGULATORY BUREAU

HFS Change Request Form

Date:
Name of Health Facility/Service
Address :
No. & Street Barangay

City/Municipality Province Region

Latest LTO/COA/ATO/COR No. Validity Period from to

Tel. Number (HF landline) Cellphone No. E-Mail Address

Owner

Permit to Construct No. (if applicable)

Type of Health Facility/Service:
License to Operate:
[ ] Ambulatory Surgical Clinic Ambulance Service Provider [ ]
[ ] Birthing Home Ambulance, specify no. of vehicle/s as approved_____
[ ] Blood Bank
[ ] Clinical Laboratory
[ ] Dental Laboratory
[ ] Dialysis Clinic
[ ] HIV Testing Laboratory
[ ] Hospital [ ] General Level 1 Level 2 Level 3
[ ] Specialty, Specify ___________________________________________________________
[ ] Infirmary
[ ] Psychiatric Care Facility
Certificate of Accreditation: Certificate of Registration:
[ ] Blood Center [ ] Special Clinical Laboratory
[ ] Drug Abuse Treatment and Rehabilitation Center
[ ] Kidney Transplant Facility Authority to Operate:
[ ] Laboratory for Drinking Water Analysis [ ] Blood Collection Unit
[ ] Medical Facility for Overseas Workers and Seafarers [ ] Blood Station
[ ] Newborn Screening Center
[ ] Human Stem Cell & Cell-Based or Cellular Therapy
[ ] Occupational Establishment Dental Clinic
[ ] Private School Dental Clinic

Nature of Request/Change/Transaction (Please check [√ ] appropriate box).

Change in ABC from to Change in type of facility
Change in number of dialysis station from _ t to Change in classification (function, institutional character)
Change in Name to Change in number of ambulance vehicle from
to
Hospital upgrading from to
Change in ownership Hospital downgrading from to
Change/Additional personnel Transfer of location
Change/Additional equipment Closure of the facility, specify effective date___________

Change in service/s Other transaction, specify

Additional service/s
Note: Attached documentary requirements with change/s
Details of Request

Signature over printed name of Director/Owner Date:

Recommendation: Date:_________
For inspection
For submission of documents
For issuance of LTO/COA/ATO/COR
Form-HFS-CR-A
Recommended by: Approved by: Revision:00
03/30/2017
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Print Name and Signature