ANNEX 1 Republic of the Philippines PHILIPPINE HEALTH INSURANCE CORPORATION

City State Bldg., 709 Shaw Blvd., Pasig City Health line 441-7444; www.philhealth.gov.ph

PHIC Accre-AF-3 06/05/2012

PROVIDER DATA RECORD INSTITUTIONAL HEALTH CARE PROVIDER (IHCP)

THE PRESIDENT & CEO Philippine Health Insurance Corporation Pasig City, Philippines Sir/Madam: I, _______________________________________________, of legal age, __________________________________ with
(Position/Designation

address at _____________________________________________ and the duly authorized representative to act for and in behalf of _____________________________________, hereby submits the following pertinent information and
(name of Health Care Institution

documentary requirements under Sec. 52 L of R.A. 7875as amended by RA 9241 and its Implementing Rules and Regulations thereto.

Type of Institution: (Please shade the appropriate box)

Hospital: Award Applied For:
Center of Safety Center of Quality Center of Excellence

Outpatient Clinic: Self-assessment Scores:

Pt. Rights & Organizational Ethics _____%

Single service _____% _____% _____% _____% _____% _____%

2-in-1

3-in-1

Multiple

Ambulatory Surgical Clinic (ASC) Freestanding Dialysis Clinic (FDC) Primary Care Benefit Provider Maternity Care Package Provider Anti-TB/DOTS Package Provider Outpatient Malaria Package Provider Animal Bite Treatment Package Provider
Other Package Provider (Specify):

Hospital Level:
Level 1 Level 2 Level 3 Level 4

Patient Care Leadership and Management Human Resource Management Information Management Safe ractice and Environment Improving Performance

Core indicator

_____%

Facility Ownership (Please shade the appropriate box) Government Private

Province City/Municipality University
Initial Renewal Late Filer

DOH Military/Police Others

Re-accreditation with gap in accreditation Upgrading/add'l services

Single proprietorship Partnership Corporation

Foundation Cooperative Others _________________

Type of Application: (Please shade the appropriate box)

Change in location/ownership

Accreditation No.

Name of Institution:

(Please print legibly and provide appropriate spaces)

Mailing/Billing Address:
No. / St. / Brgy.

Municipality / City

Province

Zip Code

Other Contact Information

Contact No. Fax No. Email Address:

Medical Director/Chief of Hospital (if applicable)

Accreditation Number (If applicable)

Head of Facility

Administrator (If applicable)

Owner of the Institution

For PhilHealth Use Only

Date Evaluated:
SO PhRO

By:
SO

_______________________ Control No. OR No. ______________________ Date Paid: _____________ AmtPaid:_______________

Date Received:

SO PhRO SO/PhRO(Receiving Module) PhRO (Data Entry)

By:

SO PhRO SO PhRO

Date Encoded:

By:

Accreditation Department 03292012