Republic of the Philippines

Department of Health
HEALTH FACILITIES AND SERVICES REGULATORY BUREAU

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 Function Service Capability
[ ] Government [ ] General [ ] Level 1
[ ] Private [ ] Specialty [ ] Level 2
[ ] Level 3

Ancillary and Other Clinical Services:

[ ] Clinical Laboratory [ ] Diagnostic X-ray Services
[ ] Primary [ ] Level 1
[ ] Secondary [ ] Level 2
[ ] Tertiary [ ] Level 3
[ ] Blood Bank [ ] Specialized Diagnostic X-ray Services
[ ] Blood Collection Unit [ ] Computed Tomography
[ ] Blood Station [ ] Mammography
[ ] HIV Testing Laboratory [ ] Digital Subtraction Angiography
[ ] Laboratory for Drinking Water Analysis [ ] Cardiac Catheterization
[ ] Drug Testing Laboratory [ ] Angiocardiography
[ ] Screening [ ] Percutaneous Transluminal Angioplasties
[ ] Confirmatory [ ] Bone Densitometry
[ ] Tumor Localization and Simulation
[ ] Pharmacy [ ] Others, please specify
No. of satellite, please specify [ ] Dental
[ ] Panoramic
[ ] Dialysis Clinic [ ] Cephalometric
[ ] Ambulatory Surgical Clinic [ ] Radiation Oncology
[ ] Conventional Radiation Therapy
[ ] Birthing Home or CEmOC [ ] Stereotactic Radiosurgery (SRS)
[ ] Intensity Modulated Radiation Therapy (IMRT)
[ ] Others, please specify [ ] 3D Conformal Radiation Therapy
[ ] Total Body Irradiation (TBI)
[ ] Others, please specify

Status of Application : [ ] Initial [ ] Renewal

License No. ___________________________
Date Issued ___________________________
Expiry Date____________________________
Form-HOS-OSS-HOS-LTO-A
Revision:01
12/08/2014
Page 1 of 5
 Checklist of Application Documents
1) For INITIAL or RENEWAL, please tick () the appropriate boxes under column B or C and provide necessary documents.
2) 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 B C
Documents Initial Renewal
Application 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
1.3.2 OSS License to Operate
1.4. List of Equipment/ Instrument (use ANNEX B)
1.5. Health Facility Geographic Form (Location Map)
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. 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
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/ radiotherapy technologist
4.4.1.1. PRC ID (for radiation oncologist and radiotherapy
technologist)
4.4.1.2. Specialty Board Certificate (for radiation oncologist)
Form-HOS-OSS-HOS-LTO-A
Revision:01
12/08/2014
Page 2 of 5
 A B C
Documents Initial Renewal
Application Application
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

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
7.3. List of Equipment, Laboratory Ware and Materials (use ANNEX H)
7.4. Certificate of Inclusion in the Official Blood Services Network of
NVBSP
7.5. List of Blood Stations and Blood Collection Units within the network
7.6. Documented Blood Transfusion Committee
Form-HOS-OSS-HOS-LTO-A
Revision:01
12/08/2014
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 A B C
Documents Initial Renewal
Application Application
7.7. 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
10.2.1.1. PRC ID
10.2.1.2. PAM Registration, if applicable
10.2.1.3. Certificate of Training
10.3. 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
11.2.1.3. Certificate of Training
11.3. 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. List of Personnel (use ANNEX A)
12.2. Photocopies of the following:
12.2.1. Proof of qualification
12.2.1.1. PRC ID
12.2.1.2. Specialty Board Certificate
12.2.1.3. Certificate of Training
12.3. List of Equipment/ Instrument (use ANNEX B)
Form-HOS-OSS-HOS- LTO-A
Revision:01
12/08/2014
Page 4 of 5
 Acknowledgement

Republic of the Philippines )

City/Municipality of _______________ ) S. S.

I, ____________________________, ____________________________, of legal age,

Name Designation
______________, a resident of __________________________________________________,
Civil Status 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

_______________ 20___.

NOTARY PUBLIC
My Commission Expires
December 31, 20______

Doc. No. _________ ;

Page No. ________ ;
Book No. ________ ;
Series of 20_______
Form-HOS-OSS-HOS- LTO-A
Revision:01
12/08/2014
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