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REQUIREMENTS F R THE
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ACCREDITATION Of rft#EEDICAL IT I
SERVICE PROVIDER I·
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~ · · · . ANNEX "l"
REQUIREMENTS ·F~R THE ACCREDITATi°ON OF MEDICAL IT SE~VICE PROVIDE
•. ·. . I

I. ACCREDITATION

An Accreditation is an official document issued by the LTO that authorizes any perso ,
natural or juridical, to provide IT services to medical clinics in accordance with t e
standards and procedures set forth by the LTO. It shall be valid for a period of one ( )
year and renewable for the same period.

There shall only be four (4) Medical IT Service Providers to be issued of accreditati I

and on a first come first served basis, but may later be increased over time as deem
necessary by the LTO so as not to affect th·e delivery of public service.

II. QUALIFICATIONS l J
Any natural person who is at least 18 years of age or any juridi,cal person with o
derogatory record or who is not otherwise disqualified by any existing law or regulati n
including the applicant's personnel, may apply for an authorization provided that ttie
requirements herein are complied with; provided further, that no DOTr/LTO personn~I,
his/her spouse, or his relative by consanguinity or affinity within the third civil degre ,
shall have ownership of or any beneficial and/ or financial interest therein.

Medical IT Service Providers or any of its personnel shall take no ·interest, directly r
indirectly, over ownership, control, or management of any medical: clinics engaged n
the business of issuing medical certificate for LTO's drivers license related transaction ,
nor shall they nave any financial or material interest in any transaction relative to the
operation of medical clinics which .tends tc(conflict with their functions to the prejudice
the public interest. ·
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Ill. DOCUMENTARY REQUIREMENTS

a. New Application

1. Letter of Intent;
2. Duly accomplished application form, under oath;
3. For sole proprietorship, DTI Certificate of Bu siness Name Registration f · r
·sole proprietorship; \
4. For corporation and partnership, Securities and Exchange Commissior
Certificate of Registration, Articles of Incorporation/ Partn ers hip and By-LaWiS
and Secretary's Certificate specifying the name of the authorize
representative who must be an officer of the corporation/partnership;
5. For cooperative, Cooperative Development Autho rity Certificate
Registration, Articles of Cooperation and By-Laws, and Secretary'
Certificate specifying the name of the authorized representative who must b
an officer of the cooperative;
6. Certified True Copy of Mayor's or Business Permit;
7. BIR Registration and Tax Identification Number;
8. SSS Membership Certificate;
9. Audited pre-operating Financial Statements showing the financial capacity
the applicant to operate for at least two (2) years;
10. Location map and layout of th e office, including dimensions;
11. Organizational structure showing the relationship between the provider an
other operations of the firm, when applicable , and the structure of the offic"
showing its personnel and their functions 1

• List cf personnel with their job descriptions·, responsibilities an~

qualifications I
• List of equipment, including manuals and reference ;materials \

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. .. i. ANNEX "i"
• Source Code and compiet~ description of executable files. Sour e
code shall be open for Assessment Team evaluation and shall only ~e
compiled in the presence of Assessment Team or c;iny of its authorizJd
representatives. ·
12. Bank Certificate of Deposit in the amount of not less than P5,000,000.00;
13. Payment of Application· Fee of ten thousand pesos (P10,000) which is no' -
refundable
14. Such other documents or requirements that the DOTr/LTO may require fro
time to time to protect the interest of the government and the public.

b. Renewal of Authorization

1. Duly accomplished application form , under oath

2. Original LTO Certificate of Authorization
3. Certified true copy of Mayor's Permit
4. Income Tax Return for the current year, duly stamped and received by t e
BIR i
5. Duly Sworn Affidavit attesting to its_ continuing compliance with all t e
requirements for authorization , unless there are changes thereto, in whi. h
case the applicant shall submit the applicable documents
6. List of Medical Clinics/Clients
7. Payment of Renewal Fee of five thousand pesos (PS,000) which is non-
refundable
8. Such other documents or requirements that the DOTr/LTO may require
from time to time to protect the interest of the government and the public.

IV. FILING

The documentary requirements for the application must be filed at the LTO Centr I
Office- Management Information Division which shall review and evaluate
completeness and authenticity and shall approve the application.

IV. PERSONNEL

The Medical IT Service Provider shall consist of the foUowing person nel '.

a. IT Service Manager
Manage overall operations of the company; ensure proper, reliable and high lev
standards of IT services provided to medical clinics;

b. Technical Personnel
Must be a graduate of any IT-related course with appropriate trainings an
backgrounds on network and database management. He shall maintain th
network and database

c. Programmer
Must have education, trainings and background in software development with
least a year of experience as programmer in a company. He must be a full stac
developer (must be able to work on both the front-end and back-end portions of a
application)

d. Administrative Assistant
Provide office or administrativ~ support/fun ctions in th e company

V. OPERATIONAL, SOFTWARE AND HARDWARE REQUIREMENTS

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 ANNEX" · "
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a. All Medical IT Service Provider sh:all provide the medical
Application Program that shall adhere to the following specs:

1. The Application Program must be a web based application for data transmissi n
and authentication.
2. The application program shall automatically synchronize the date and time oft e
workstation to the Medical IT Service Provider servers and the LTO IT System.
3. The Application Program shall automatically detect the biometric systems a d
computer-based medical equipment. The program shall prompt the user if a
device is disconnected.
4. No medical result transmission shall be delayed. The medical result shall e
transmitted to the IT Provider and LTO's servers real-time.
5. The Application Program shall require a fingerprint verification to be able to I g
into the application program. For uniformity and to ensure compatibility to t e
new LTO-IT System, the current LTO fingerprint scanner (Dermalog) shall e
used by all medical clinics.
6. Fingerprint verification of the examining registered physician shall be required
the application program for each medical result to authorize the upload.
7. The Application Program shall be integrated with computer based acuit ,
contrast sensitivity and auditory test equipped with a digital camera & signatu e
pad to capture the photograph & signature of the driver/conductor applicant.
8. The Application Program shall not accept medical results generated by oth r
software.
9. Only the physicians who are qualified and enrolled in the system shall be able o
access and transmit medical result.
10. The application program shall be ready to be integrated to the incoming ne
LTO IT System.
11 .The application program shall automatically generate the results based on th
outcome of the examination and shall conform to the prescribed medical res It
format.
12.The application program shall not allow any form of modification on the resul s
of the medical equipment interfaced with the workstation.
13. The application program shall not allow re-exam ination of failed applicants f r
one (1) day and until sufficient documents or clearance from the medic11
specialist are shown that prove s the impairment of the applicant was corrected.
14. The application program shall not start the examination unless all medic I
equipment necessary are connected to the workstation.
15. The application program shall follow the ·prescribed medical result format i
data transmission. Transmission and printing of medical certification/result sh II
not be possible unless all data required are present as well as the duratio
(8mins) of all medical examination procedures has been consumed.
16. All medical result transmitted shall have a unique identification numb r
generated automatically by the application program.
17. The application program shall l:<eep medical records for ten (10) years until th
record can be deleted .
18. The Application Program shall include a timer to show how much time is le t
before proceeding to the next step of the medical examination. The applica t
cannot proceed to the next step until the allotted time for the correspondin
step is con sumed.

b. A!I source code which must be submitted to the LTO Management Information Divisio
for evaluation and approval; and shall only be compiled in the presence of any LTO-Ml
authorized representatives

c. System set-up and network layout

d. The Medical IT Service Provider mu st have a main database server that shall acce t
incoming medical result transmissions from the clinics and shall have another separat
 I
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ANNEX""'"

active database server acting as backup. The rnain database server a nd the bacl<~p
database server shall be both active but shall not be contained in the same bu ilding.
The Database Server must be capable to store 10 years worth of medidal
results/certifications and shall be installed with the latest software and drivers. I
e. The Medical iT Service Provider ~ust have its own Domain Name and shal l be the oje
to host the medical application program. ·1

f. The Medical IT Service Provider shall provide a Virtual Private Network to the Medic~I
Clinic to secure medical result transmission. . \

g. Medical IT Service Provider is required to report incident or any technical breach with\n
twenty-four (24) hours from the time of its occurrence including but not limited to failu fie
to upload medicai test results; · I
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h. No re-print request shall be authorized if the present date is later than fifteen days fro~i
the date and time the DL applicant is checked-up by the registered LTO physician: i
i. No demo transaction shall be uploaded to tile LTO !T System; I I

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-1.·k1t is noted however that the medical clinics may be able to directly upload the medic~I
examination results/certificates, without interces~'ion of the IT Providers, in the New LTO If
System through the LTO Portal once the development of the application software has beer
completed. . \

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DR.IVER'S MEDICAL EVALUATION
FORM

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ANNEX B

DRIVER'S MEDICAL EVALUATK@!Nl

(Medical information is CONFIDENT/AL)

INSTRUCTION: Complete and sign before ~ubmitting to the examining physician. PLEASE WRITE

t?SECTION 1·- ADVIS().RY STATEMENT . . .

Medical information provides the examining physician an overview of your general health and e able him/her
to focus on certain aspects which may require further examination and/or testing. The data on your physical
and mental fitness is required to determine your· driving qualifications. Failure to provide th information
required herein is cause for refusal to issue a license or to withdraw driving privilege.

You are required by law to disclose any and all conditions that could affect the safe operati n of a m_otor
vehicle. Willful misrepresentation with respect to material information in driver's/conductor's lice se application
including health condition/s is punishable by a fine of P20,000.00 (Section 23-8 of R.A. 4136, as a ended by R.A.
·10930).
t?SECTION 2 - APPLICANT INFORMATION ·'. '" "·
NAME (LAST, FIRST, MIDDLE) BIRTHDATE (mm/dd/yyyy) AGE

COMPLETE ADDRESS I NATIONALITY CIVIL STATUS

Student-Driver's Permit Nonprofessional New Renewal LICENSE NO.

Conductor's License DL
Professional DL Miscellaneo us
!~'SECTION 3 '.'"COMPLETE HEAii.TH HISTORY
HAVE YOU BEEN DIAGNOSED, TREATED OR CONFINED FOR THE FOLLOWING? (Ex lain any "YES" answers ir space belo~
YES NO YES NO

Hearing or ear problems

H . ertension or other cardiovascular disease Re ular or fre uent alcohol/dru se
Heart attack, stroke, or · aral sis Involved in a motor vehicle acddei_t_w- ~_-ile-_dri~~
An ma·or illness, in'ur or o erati~n ___
An ermane~t im airment I ___ ___
Diabetes or hi h b!ood su ar Other disorders or diseases I
EXl?LANA'ilON FOR YES ANSWERS:(lndude onset date, diagnosis, medication, and any current condition or ~imitation)

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~SECTION 4 - PRESENT CONDITION/S AND TREA'fMENT
ARE YOU PRESENTLY EXPERIENCING ANY ADVERSE SYMPTOM/S THAT NEED MEDICAL ATIENTION? If Yes, Fplain.
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o Yes o No
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HOW OFTEN DO YOU SEE A PHYSICIAN? D/.\TE OF LAST EXAMINATION BY A tHYSICIAN:

HAVE YOU BEEN HOSPITALIZED WITHIN THE LAST FIVE (5) YEARS? DATE OF LAST CONFINEMENT (If apbtk~f;'(;j-:_ !'_ __:_

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LIST THE MEDICATIONS PRESCRIBED OR USED REGULARLY OR RECEN TLY (Please inc u e d osage and firequ ncy of use) J

IMPOIRTANT

I certify to the best of my knowledge under penalty oi ~errjury that the information I have provided ir the preceding
sections of this form is true and correct. I undersiam1dl that any inaccurate, fa lse, or missing in~ ormation may
invalidate the medical examination and the correspomlling medical certificate.
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DATE APPLICANT'S SIGNATURE OVER PRINTIED NAME
_/ /__ __
mm dd yyyy
!~SECTION 5.- MEDICAL .INFORMATION:'AUTHORiZATiON ;
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ACCREDITED MEDICAL CLINIC (NAME AND ADDRESS)

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I hereby give my consent, as data subject, to the collection and processing of my personal informatio \ including my
sensitive personal information, privileged info rmation, and that information pertaining to my health as a result of the
medical examination to be performed, by the above-named medical clinic and its examining physician. I f1 urther authorize
said medical clinic transmit to the Land Transportation Office t he information required in my application for I cense.

I hereby authorize the Land Transportation Office to receive information relating to my physical and m "ntal condition,
and/or drug and/or alcohol use or abuse, and to use the same in determining my fitness to operate a motor wehicle safely.

DATE
_ _/ __ / __ APPUCANT'S SIGN.ATUR~ OVER PRINTED NIAME

mm dd YYW

STOP! DO NOT WRD'f!E £8~YOND THIS PORTION.

Fields below to be filled up by authorized medical clinic personnel/examining physician otly.

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~;SECTION 6-INITIAL ASSESSMENT
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HEIGHT (CENTIMETERS): WEIG HT (KILOGRAMS): BODY MASS INDEX (BMI) EYE COLOR: BLOOD TYPE:

Information provided by applicant

BLOOD PRESSURE (mmHg): BODY TEMPERATURE: PULSE RATE: RESPIRATORY RATE:

REMARKS (Include observations that may affect safe driving):

Initial Assessment performed by:

Name and Signature of Medical Clinic PE ·sonnel

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~\SECTION 7- EXAMINING PHYSICIAN'S INFORMATION AND SKGNATURE :-:;· ·,_:~~~
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I have revi ewed the foregoing medical information of the applicant whi ch shall be the basis fo r an in-depth medical e>can ination and in
the issuance of the corresponding medical certificate.

SIGNATURE OF REGISTERED EXAMINING PHYSICIAN ·- . Nt._ME OF EXAMINl.NG.P_lj'(SICIAN

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DATE OF EXAMINATION PRC LICENSE NO.

SERIAL/REFERENCE NO. OF MEDICAL CERTIFICATE ISSUED:

NOTE: THIS DOCUMENT MUST BE l<EPT ON FILE BY THE MEDICAL CLINIC FOR AT LEAST TEN (10) YEARS.

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MEDICAL CERTI FICATE FORM
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MEDICAL CERTIFICATE FOR DRIVERS LICENSE

APPLICANT'S INFORMATION

NAME:
SURNAME FIRST NAME MIDLLENAME
ADDRESS:
-----------------------------
DRIVER LICENSE NUMBER: _ _ _ _ _ _ _ _ _ _ DATE OF BIRTH: _ _ _ _ _ __
NATIONALITY: _ _ _ _ _ _ _ _ AGE: _ _ GENDER: MARITAL STATUS._·_ _

PHYSICAL EXAMINATION

GENERAL PHYSIQUE CONTAGIOUS DISEASE BLOOD PrESSURE

D Normal 0 Normal
D BLOO TYPE
With Disability D With Disease, pis specify: _ _ _ _ __

d
HEIGHT:_ _ (cms) WEIGHT: _ _ (kgs)
UPPER EXTREMITIES: LOWER EXTREMITIES:
LEFT RIGHT LEFT
D Normal D Normal D Normal DGH~ormal
D With disability D With disability D With disability D With disa ~ility
D With special equipment D With special equipment D With special equipment D With spec al equi pment

VISUAL TEST .___ _ _ _ _ ~A_u_D__1T_o_R_v_T_E_sT_---!-j__ ~

Visual Acuity: LEFT EAR: RIGHTE~R:
LEFT EYE: SNELLEN/BAILEY-LOVIE - - - -
D
~~~c~d
Noni al
0 With corrective lens
D HeduFed
D Color blind
With hearing aid 0 With hea ring aid

0
RIGHT EYE: SNELLEN/BAILEY-LOVIE - - -
With corrective lens
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D Color blind C-
.D
ASSESSMENT
·-----------;----~
Fit to drive I
METABOLIC AND NEUROLOGICAL DISORDERS D Unfit t o d rive \
O Permanent

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D Yes D No DIABETES
Is it under proper control or medication? D Yes D No D Temporary

D Yes D ~Jo EPILEPSY Date of last seizure _ _ __ D Refer to Specialist for f urtht;:r Evaluation

Is it under proper control or medication ? D Yes D No I CONDITIONS I

1- - - J
D Yes D No SLEEP APNEA 0 None \
Is it under medication ? D Yes D No D Drive only with corrective lens .

D Yes D No AGGRESSIVE, MANIC OR DEPRESSIVE ORDER O Dcive only w;th special equipment io\Uppec !inibs
Is it under proper treatment or medication ? Yes D No D D Drive only with special equipment fol lower limbs
D Yes D No OTHER MEDICAL CONDITION OR IMPAIRMENT
WHICH MAY AFFECT ABILITY TO DRIVE SAFELY
Is 1t under proper treatment or medication? D Yes D No Drive only with hearing aid

PHYSICIAN REMARKS: - .
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PRC LICENSE NUMBER \ -·ir-;.::-:-.-..- .:-.
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CERTI FICATE# \Ill \ ...
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SIGNATURE i , I' ' · ~ \{~?,.J;>AY~/,FROIVI PATE OF ISSUE) '\
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APPLICATION FOR ACCREDITATION
OF MEDICAL CLI NIC

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 Republic of the Philippines

~~ Departmen_t of T_ransportation
~
--- APPLICATION FOR ACCRE DITATION OF MEDICAL CLiNIC
L AND T RANSPORTATION OFFICE

Name of C lin ic I I
Address of Clinic I I
I No. & Street Bar angay C ity/Mu nicipalily ! Province Zip Code I
Contact Number I I Fax No.
I I E-mail Address
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Owner of Clinic I ' I
Type of O rganization (Please Check) Classification: Type of Healt h Facility o r Ser vices:

D Sole P roprietorship D Corporation D Private CJ Medical C linic

D Partnership D Cooperative CJ Government CJ Others (Specify)
Statu s of Application: I I
D Initial c::J Renewal L TO Service Area IT Service Provi der

Documentary Requirements: (Please present the original s)

PRIVATE CLINIC GOVERNMENT CLINIC OR HEALTH FACILITll:S
D 1, Duly accomplished application form under oath signed by the owner : D 1, Duly accomplished application form under oath !signed by
D 2. Ce11ified true copy of the following: the Head of Agency;
I
a. For sole proprietorship, Certificate of Business Name Registration; D 2. Health Facility geographic form (location map) (An 1ex D) and
layout of the cli~ic, including
b. For corporation/partnership, Securities and Exchange Commission Certificate of
Registration and Articles of Incorporation/Partnership and Board Resolution issued dimensions; '
by the Board Secretary, specifying the name of authorized repres entatives who
must be an omcer of the corporation/partnership; or D 3. Photographs or the exterior and interior of the n edical
clinic;
c. For cooperative. Cooperative Development Authority Certificate of Regislration and
Articles of Cooperation and Board Resolution, Issued by the Board Secretary,
D 4. Chart of organizational structure showing its p~sonnel and
their positions;
specifying the name of authorized representative who must be an officer of the
cooperative: D 5. List of personnel involved with the operation inc uding their
CJ 3. Mayor's Permit or Permit to operate business issued by the proper local government job descriptions, responsibilities and quallficati ns.

D 4.
unit;

Bureau of Internal Revenue Registration and Taxpayer's Identification Number;

including the certified true copy of their approve
appointments or certificates of employment; 1
D s. Audited Financial Statement for the last two (2) years or a Pre-operating Financial D 6. List of all equipment, including manuals. refer nee
materials required for its calibration; and
Statement whichever is applicable. showing that the owner-applicant shall b:;, in s uch
financial condition as to reasonably expect it to operate for at least one ( 1) year;
Such other documents that the l TO may requi e from time
CJ 6. Health Facility geographic form (location map) (Annex DJ and layout of the clinic, CJ 7. to time to protect !he interest of the government and the
including d imensions; public.

D 1. Certificate of Registration of personal information processing system as proof of

registration with the National Privacy Commission in accordance with Republic Act No.
101 73 or !he Data Privacy Act;
D a. Photographs of the exterior and interior of the medical clinic;
CJ 9. Chart of o;ganizational structure showing the relationship between the clinic and other
operations of the firm, when applicable, and of the clinic showing its personnel and its
functions;

CJ 10. list of personnel involved with the operation of the clinic including their job descriptions.
responsibilities and qualifications, including the Certificate of Registration duly issued
by !he Board of Medical Examiners to physician/s and nurse/s employed therein;

D 11 . List of all equipment. computer based examination Including manuals,

reference materials required for its calibration;
CJ 12. Such other documents that the l TO may re quire from time to time to protect the interest
of the government and the public

I declare under oath that I have personally accomplished the Application for Regist ration of Physician which is a true, correct a nd complete sta~ement
pursuant to the provisions of pertinent laws, rules and regulations of the RepL1b!ic of the Philippines. I authorile the registering a gency h ead/a thorized
representative to verify/validate the contents stated herein . I agree that a ny misrepresentation made in the document and its attachme nts shall cause
the filing of administ rative/ c riminal easels against m e .
i

Pri nted Name and Signature of Applicant Designation Date of Applic i tion
'

Subscribed and sworn to m e befor e thi s day of affiant exhibiting to me hisli1er Residence Cet1icate
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No. l ·issued at ,.
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Book No.
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Evaluated by: Date: Approve d by: Date: L TO Accr editation t umbe r:

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L TO Auth orized Personnel L TO Authorized Signatory V a lidity:

(Printed Name & Signature) (Printed Name & S ignature)
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ANNEXE
HEALTH FACIL~TY G EOGRAPHIC
FORM

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REPUBLIC OF THE PHILIPPINES
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LAND TRANSl?ORTATION OFFICE
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HEALTH FACILITY GEOGRAPHIC FORM
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2. Region: I
(example: Region 1- !locos Region)
I 3. Street name and number:
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r~. Building name and number:
(Write N/A_ if none)
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5. Province:
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6. C&ty/Mu nkipality:
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7. Barangay:
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8. Nearest LTO Office:
(example: San Fern ando Distri~_ Office) ·
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1 _9. Cont act Number:
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Can it be located using Google Map? ·
(Yes o r No)
11. Zo om Scale: . ±'
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12_ ~~~u~r.~cm) __ - ___·. ___ _____- - - -:..._____
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13. longitude:
{e>cample: 120.318509)
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*Attach t wo copies of streensflot of the Medk a.i CHnic/ Fad !itv using §ooJllitMap SatelU~i

*Attach vour Floor Plan/Clink l arvout .

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Steps on how to get the Lat it ude and longitude: i
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L Go to htt ps://www.google.com. ph/m <1J.:'.li. website. I
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ss/loc;ation ln the SEf:.\~CH GOOGLE MAPS BA.R.

2. Input your addre_
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 Luzon

Manila
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Philippines
Panay ·
Cebu
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Palawari Negros
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,P~lau ;· ··.: .L.-

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·Davao ,
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Search this area

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Map d••• ~2018 Google, ZENRI N ?!lilippipe:o Terms
Seod reedbaci<

3. After searching your address/location, click on the "Satellite" to change view.

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4. Right Click on your Medical Clinic/Facility and select "What's Here?" to show the
Latitude and Longitude (Latitude is foll owed by Longitude). Zoom. scale can be foun1 at
the bottom right of Google Maps (Click on the scale meter to change unit of [
measurement ). ~ . I

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Directions frorr i here

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Wh at's here? ~

Pri11t
Ad el <=; 1nissing plar:e

Measure distance

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 ANNE F
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APPLICATION FOR REGISTRATION F
PHYSICIAN f ORM

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Republic of the Philippines
PHOTO OF
Department of .Tran~portation
REGISTERED
LAND TRANSPORTATION OFFICE
PHYSICIAN
(With name fag; fa en
APPLICATION FOR REGISTRATION OF PHYSICIAN by L TO immediat y
after registration

Clinic Name

Address

Sex c:J Female D

First Name Email Address

Middle Name Contact No.

Birth Date PRC No.
Month Day Year Specialization (if any)

Signature over Printed Name Date

lndorsed by:

Signature over Printed Name of Clinic Owner/Authorized Representative Date

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Documents Submitted by Applicant: -»--1 "' -

D Two pieces 2x2 photo with name tag within the last three months Clinic Code =====!===================
D
from the date of application for registration;
Certified true copy of Ce1tificate of Registration duly issued by
the Board of Medical Examiners;
Username c ___. ___________. ,___,
0 Certificate of Membership and good standing from the Medical
Association of its component society;
D Photocopy of the valid Professional Regulation Commission Registered by: Date:
license card (original copy presented during registration);
D Copy of valid government issued identification card (other than
PRC) with photo and signature (original copy presentad during
registration); LTO Authorized Personnel
D Current Professional Tax Receipt (PTR} number except for (P1i11ted Mame & Signature)
government physician;
D Taxpayer's Identification Number (TIN);
D Digital Photograph and Biometric Scan of the Physician;
0 For government physicians, certified true copy of approved
appointment or Certificate of Employment issued by the agency;
D For government physicians who desire to engage in private
practice, Authority to Engage in the Private Practice of Profession
approved by the Head of Agency where he/she is employed.

Approved by: Date:

LTO Authorized Signatory

(Printed Name & Signature)

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