Application for License to Operate a Hospital

Name of Hospital Complete Address No. & Street City/ Municipality Region Telephone and/or Fax Number Name of Owner Chief of Hospital/Medical Director Chairman of the Board (If Corporation) Authorized Bed Capacity Classification: Ownership [ ] Government [ ] Private : : : : : : : Function [ ] General [ ] Special Service Capability [ ] Level 1 [ ] Level 2 [ ] Level 3 [ ] Level 4

Ancillary and Other Clinical Services: [ ] Clinical Laboratory [ ] Primary [ ] Secondary [ ] Tertiary [ ] Blood Bank [ ] Blood Collection Unit [ ] Blood Station [ ] HIV Testing Laboratory [ ] Laboratory for Drinking Water Analysis [ ] Drug Testing Laboratory [ ] Screening [ ] Confirmatory [ ] Pharmacy No. of satellite, please specify [ ] Dialysis Clinic [ ] Ambulatory Surgical Clinic [ ] Birthing Home or CEmOC [ ] Others, please specify

[ ] Diagnostic X-ray Services [ ] Level 1 [ ] Level 2 [ ] Level 3 [ ] Specialized Diagnostic X-ray Services [ ] Computed Tomography [ ] Mammography [ ] Digital Subtraction Angiography [ ] Cardiac Catheterization [ ] Angiocardiography [ ] Percutaneous Transluminal Angioplasties [ ] Bone Densitometry [ ] Tumor Localization and Simulation [ ] Others, please specify [ ] Dental [ ] Panoramic [ ] Cephalometric [ ] Radiation Oncology [ ] Conventional Radiation Therapy [ ] Stereotactic Radiosurgery (SRS) [ ] Intensity Modulated Radiation Therapy (IMRT) [ ] 3D Conformal Radiation Therapy [ ] Total Body Irradiation (TBI) [ ] Others, please specify [ ] Renewal License No._____________________________ Date Issued_____________________________ Expiry Date_____________________________

Status of Application

: [ ] Initial

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Checklist of Application Documents 1) 2)

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

Required For All Hospitals

1. Hospital 1.1. Notarized duly accomplished Application for License to Operate a Hospital (this form) 1.2. List of Personnel (use ANNEX A) 1.3. Photocopies of the following: 1.3.1. Proof of qualification 1.3.1.1. PRC ID 1.3.1.2. Certificate of Training 1.4. List of Equipment/ Instrument (use ANNEX B) 1.5. Location map for the hospital 1.6. Photographs of the exterior and interior of the hospital 1.7. Annual Hospital Statistical Report 2. Clinical Laboratory 2.1. List of Personnel (use ANNEX A) 2.2. Photocopies of the following: 2.2.1. Proof of qualification of pathologist and medical technologist 2.2.1.1. PRC ID 2.2.1.2. Specialty Board Certificate (for pathologist) 2.2.1.3. Certificate of Training 2.3. List of Equipment, Reagent, Laboratory Ware and Materials for Specific Test (use ANNEX C) 2.4. Quality Manual (to be fully implemented by January 1, 2009) 2.5. Certificate of Participation in External Quality Assurance Program 2.6. Memorandum of Agreement, if not owned by the hospital 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

Submit changes only

3.3. List of Products (use ANNEX D)

3.4. Memorandum of Agreement, if not owned by the hospital 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/
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A Documents radiotherapy technologist 4.4.1.1. PRC ID (for radiation oncologist and radiotherapy technologist) 4.4.1.2. Specialty Board Certificate (for radiation oncologist) 4.4.1.3. Masters Degree in Medical Physics (for medical physicist) 4.4.1.4. Certificate of Training 4.5. List of X-ray Machines (use ANNEX G) 4.6. Acceptance/Performance Test Result for Computed Tomography and Mammography x-ray machines 4.7. Photocopy of official receipt from PNRI for new film badge subscription for one year 4.8. Photocopy of film badge personal dose evaluation reports within the validity period of the hospital license 4.9. Certificate of compliance with pre-operational requirements for medical linear accelerator facility 4.10. Facility report on the installation and commissioning of the equipment duly signed by the facilitys qualified medical physicist and the technical representative of the equipment manufacturer/supplier 4.11. Conformance testing report of the BHDT medical physics team on the x-ray units in the medical linear accelerator facility 4.12. Quality audit report of the BHDT health physics team on the medical linear accelerator facility

B Initial Application

C Renewal Application

When Provided by the Hospital

5. Dialysis Clinic 5.1. List of Personnel (use ANNEX A) 5.2. Photocopies of the following: 5.2.1. Proof of qualification of medical and paramedical staff 5.2.1.1. PRC ID 5.2.1.2. Certificate of Training 5.3. List of Equipment/ Instrument (use ANNEX B) 5.4. Manual of Operations/ SOP 5.5. Annual Summary Report of Patients Registered to the Renal Disease Registry (Certificate of Compliance) 5.6. Documented Quality Assurance Program (QAP) 6. Blood Station/ Blood Collection Unit 6.1. List of Personnel (use ANNEX A) 6.2. Photocopies of the following: 6.2.1. Proof of qualification of medical technologist and donor recruitment officer 6.2.1.1. PRC ID 6.2.1.2. Certificate of Training 6.3. List of Equipment, Laboratory Ware and Materials (use ANNEX H) 6.4. Documented Blood Transfusion Committee 6.5. Certificate of Inclusion in the Official Blood Services Network of NVBSP 6.6. Recommendation from the Zonal/ Regional Blood Services Network 6.7. Annual Accomplishment Report using NVBSP Form 7. Blood Bank 7.1. List of Personnel (use ANNEX A) 7.2. Photocopies of the following: 7.2.1. Proof of qualification of medical technologist and donor recruitment officer 7.2.1.1. PRC ID 7.2.1.2. Certificate of Training
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A Documents

B Initial Application

C Renewal Application

7.3. List of Equipment, Laboratory Ware and Materials (use ANNEX H)

7.4. 7.5. 7.6. 7.7. Certificate of Inclusion in the Official Blood Services Network of NVBSP List of Blood Stations and Blood Collection Units within the network Documented Blood Transfusion Committee Annual Accomplishment Report using NVBSP Form

8. HIV Testing Laboratory 8.1. List of Personnel (use ANNEX A) 8.2. Photocopies of the following: 8.2.1. Proof of qualification of medical technologist 8.2.1.1. PRC ID 8.2.1.2. Certificate of Training 8.3. List of Testing Materials (use ANNEX I) 9. Laboratory for Drinking Water Analysis 9.1. List of Personnel (use ANNEX A) 9.2. Photocopies of the following: 9.2.1. Proof of qualification of analyst 9.2.1.1. PRC ID
9.2.1.2. PSP Certificate, if applicable

9.2.1.3. Certificate of Training 9.3. List of Parameters for Each Service Capability (use ANNEX J 9.4. List of Equipment, Reagent, Laboratory Ware and Materials for Specific Test (use ANNEX K) 9.5. Quality Manual for Drinking Water Analysis 10. Drug Testing Laboratory 10.1. List of Personnel (use ANNEX A) 10.2. Photocopies of the following:
10.2.1. Proof of qualification of head of the laboratory, analyst and authorized specimen collector

10.3.

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)

10.4. Documentation of Chain of Custody 10.5. Quality Control Program (for screening laboratory) OR Certification for Quality Standard System by a DOH recognized certifying body (for confirmatory laboratory) 10.6. Certificate of Proficiency/ Proficiency Testing Result 10.7. Procedure Manual

11. Ambulatory Surgical Clinic 11.1. List of Personnel (use ANNEX A) 11.2. Photocopies of the following:
11.2.1. Proof of qualification

11.2.1.1. PRC ID
11.2.1.2. Specialty Board Certificate

11.3.

11.2.1.3. Certificate of Training List of Equipment/ Instrument (use ANNEX B)

11.4. List of Surgical Operations/ Procedures 11.5. Documented Quality Assurance Program 12. Birthing Home or Comprehensive Emergency Obstetric Care (CEmOC)

12.1.
12.2.

List of Personnel (use ANNEX A)

Photocopies of the following:

12.2.1. Proof of qualification

12.2.1.1. PRC ID
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A Documents
12.2.1.2. Specialty Board Certificate

B Initial Application

C Renewal Application

12.3.

12.2.1.3. Certificate of Training List of Equipment/ Instrument (use ANNEX B)

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ANNEX M Acknowledgement Republic of the Philippines ) City/Municipality of _______________ ) S. S. I, ____________________________, ____________________________, of legal age,
Name Civil Status Designation

______________, a resident of __________________________________________________,

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________