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Republic of the Philippines

Department of Health
OFFICE OF THE SECRETARY

February 19, 2019

DEPARTMENT MEMORANDUM
No. 2019 - OU

TO : HEALTH FACILITIES AND SERVICES REGULATORY


BUREAU (HFSRB) CONCERNED PERSONNEL,
DIRECTORS OF CENTERS FOR HEALTH DEVELOPMENT
CHD), DOH-CHD REGULATION, LICENSING AND
ENFORCEMENT DIVISION (RLED) CHIEFS, AND OTHERS
CONCERNED

SUBJECT : DOH-HFSRB-QOP-01-Form 1 (New and Renewal Application)


and DOH-HFSRB-QOP-01-Form 2 (Application for Changes in
Existing Health Facilities)

To effectively implement Republic Act No. 11032, otherwise known as “Ease of Doing
Business and Efficient Government Service Delivery Act of 2018,” which amended R. A.
9485, or the “Anti-Red Tape Act of 2007, the forms used for (1) Application for License to
Operate and (2) HFS Change Request Form are hereby simplified. This will promote
streamlined businesses within the regulation of health facilities and services.

The “Application for License to Operate” was modified and renamed as DOH-HFSRB-
QOP-01-Form 1 (New and Renewal Applications). The previous form contained nine (9)
requirements (Acknowledgment, List of Personnel, List of Equipment/Instruments, List of
Ancillary Services, Application for Medical X-ray Facility, Application for Hospital Pharmacy,
Health Facility Geographic Form, Photographs of
the exterior and interior of the health facility,
Annual Statistical Report). The new form shall include only six (6) requirements, as follows:

Acknowledgment;
PWNS
Proof of Ownership and Name of
Health Facility;
Accomplished Health Facility Self-Assessment Tool
Application for Medical X-ray Facility;
AW
Application for Pharmacy; and
Health Facility Geographic Form.

These shall be used in all regulated facilities and services being. List of Personnel and
List of Equipment/Instruments are to be required during the conduct of inspection, especially
for new applicants.

Building 1, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila e Trunk Line 651-7800 local 1108, 1111, 1112, 1113
Direct Line: 711-9502; 711-9503 Fax: 743-1829 e URL: http://www.doh.gov.ph; e-mail: fiduque@doh.gov.ph
As for the “HFS Request Revision Form,” it was changed into DOH-HFSRB-QOP-01-
Form 2 (Application for Changes in Existing Health Facilities). The four (4) types of changes
covered by the previous form — change in ownership, transfer of location, hospital upgrading,
closure of the facility — shall now form part of the application for permit to construct,
excluding closure of facility, which is not within the scope of changes.

Effective March 1, 2019, the use of DOH-HFSRB-QOP-01-Form 1 and DOH-HFSRB-


QOP-01-Form 2 shall be implemented.

Accordingly, the following application forms shall be deemed superseded and obsolete
beginning March 1, 2019: Form HF-LTO-A, Form-ASC-LTO-A, Form OSS-ASC-LTO-A,
Form-BSF-ATO-A, Form-BSF-LTO-A, Form-SCF-COA-A, Form-HDC-LTO-A, Form-OSS-
DC-LTO-A, Form-CLG-LTO-A, Form-DATRC-COA-A, Form-DL-LTO-A, Application
PETITION HIV Testing Laboratory, Form-KTF-COA-A, Form LDWA-COA-A, Form-OSS-
MFOWS-COA-A, and Form-NSC-COA-A. The contents of the foregoing were already
incorporated in the health facility (HF) Assessment Tool.

Finally, to give emphasis to the strengthening of the health regulation of business


processes, please be reminded of the submission of the required reporting forms for list of the
health facilities and services (See Annex A). The period of submission shall be in accordance
with Administrative Order 2007-0021, entitled “Harmonization and Streamlining of the
Licensure System for Hospitals,” particularly sub-item h(iii) on Reports, under Item V(A)
thereof.

For compliance.

By Authority of the Secretary of Health:

HH
ROLANDO QUE D. DOMINGO, MD, DPBO
Undersecretary of Health
Health Regulations Cluster

Building 1, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila @ Trunk Line 651-7800 local 1108, 1111, 1112, 1113
Direct Line: 711-9502; 711-9503 Fax: 743-1829 e URL: http://www.doh.gov.ph; e-mail: ftduque@doh.gov.ph
*

BECP RRR REPRE

Name

Telephone No.:
DOH-HFSRB-QOP-01-Form’

of Health
HF Address
:

Status of Application:
RRP

Head of the Facility/Medical Director


Owner :
Classification According to:
Ownership: [ ] Government

Private
Institutional Character: [
[ ]
RERUN

Permit to Construct No. (If applicable)


Instruction: Please
LICENSE TO OPERATE:
[ ]

[
[
]
]
Service/s:

Birthing Home
tick
1

Facility (HF) or Service Provider

(“) the appropriate


Ambulatory Surgical Clinic

Blood Service Facility:

Clinical Laboratory
Dental Laboratory
]

(J
No. &

[
Street

City/Municipality

:
Province

]
Fax No

New

colorectal surgery
(FJ generat surgery
[J ophthalmologic surgery
[
:

pist. city. Mun]


Corporation [1] Partnership [7] Proprietorship
Institution-based ] Norrlnstitution-based

(J oral and maxillo-facial surgery


(J orthopedic surgery
(“] Blood Bank
[J
[

Date Issued
Barangay

Province

Renewal
]

License No.
R
boxes below and provide necessary documents.

Blood Collection Unit (Hosp-based)


[
Republic of the Philippines
Department

E-mail Address:

DOH-Retained
[.) Cooperative
] Free-Standing

____E—SC«Vadidity
[]
of Health
HEALTH FACILITIES AND SERVICES REGULATORY BUREAU

District

Authorized Bed Capacity


[I
Region

[1 university others, Specify.


Foundation [J

(ABC)

(_] otolaryngologic surgery


(FJ pediatric surgery
[J
:

plastic and reconstructive surgery


[_] reproductive health surgery
(J thoracic surgery
(CJ urologic surgery

C1 Blood Bank w/ Addt'l. Function


[-] Blood Station (Hosp-based)
PN ~a
ysHENS

ee

Dialysis Clinic
HIV Testing Laboratory

1
Hospital
Function: [ ] General Level Level 2[O Level 30
{ ] Specialty, Specify
Infirmary

| [J
Psychiatric Care Facility [[] Acute chronic Custodial
J
Il
age

Ambulance Service Provider No. of Ambulance Unit: Type Type


CERTIFICATE OF ACCREDITATION:
Drug Abuse Treatment and Rehabilitation Center [_] Residential [-] Non-Residential
Dental Clinic [_] Occupational Establishment [2] Private School
Human Stem Cell and Cell-Based or Cellular Therapy Facility
Kidney Transplant Unit
sees es

Laboratory for Drinking Water Analysis [-] Bacteriological [1 Chemical [J Physical


Medical Facility for Overseas Work Applicants CO Regular Medical Facility
CJ Special Seafarer’s Med. Fac. 1] Special Land-based Med. Fac.
Newborn Screening Center
AUTHORITY TO OPERATE Free Standing) (For
[ ] Blood Collection Unit [ ] Blood Station
CERTIFICATE OF REGISTRATION:
[ Special Clinical Laboratory [[] Clinical Pathology [—] Anatomy
]__

Service Capability, Specify.


Documents New Renewal
1. Acknowledgement (notarized)
2. Proof of Ownership and Name Health Facility: of
2.1 DTI/SEC/CDA Registration including Articles of Incorporation/Cooperation and By-Laws
2.2 Enabling Act/ LGU Resolution (for government health facility)

3. Application Form for Medical X-ray Facility (if applicable)

4. Application Form for Pharmacy (if applicable)


5. Accomplished Health Facility Self-Assessment Tool

6. Health Facility Geographic Form (Geographic Coordinates)

Note: Please refer to www.hfsrb.doh.gov.ph. for other details of the requirements. !


DOH-HFSRB-QOP-01 Form1 |

i Rev:00 :

i
3/1/2019 |
Name and Signature of Applicant Date of Application i
settee Page 1of2.3
*
*
Acknowledgement

REPUBLIC OF THE PHILIPPINES __)


CITY/
MUNICIPALITY OF )$.S.

I, ' ,
Of legal age, _————«,: aa:sresident of
Name Civil Status Age
, after having been sworn in accordance with law
Address
hereby depose and say that |
am executing this affidavit to attest to the completeness and truth of the foregoing
information and the attached documents required for the establishment/operation of health facility pursuant
to existing rules and regulations. That the undersigned is aware and informed that any misrepresentation,
falsification/deception herein can cause the denial of my application.

Signature

Before me, this day of 20_. 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.
Owner Community Tax Number Issued at/ on

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,
| have hereunto set my hands this day of ,20.

Doc No. NOTARY PUBLIC


Page No. My Commission Expires
Book No. Dec. 31, 20
Series of

DOH-HFSRB-QOP-01 Form1
Rev:00 :

3/1/2019
os
Republic of the Philippines
Department of Health
HEALTH FACILITIES AND SERVICES REGULATORY BUREAU
DOH-HFSRB-QOP-01-Form 2
BEEBE ROR RRR RRR RRR RRR ERR
Date: ——————______

:
Name of Health Facility (HF Service Provider
HF Address
ERECT RRR RRR RRR RRR RRR RRR RRR
RRR
No. & Street Barangay District

City/Municipality Province Region


HF Landline No. Mobile No. E-Mail Address
Owner

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


Permit to Construct No. (if applicable) Date Issued:
Type of Health Facility/Service:
License to Operate:
[ ] Ambulatory Surgical Clinic [ ] Ambulance Service Provider
[ ] Birthing Home Ambulance unit/s approved: No. Type
[ ] Blood Service Facility (Hosp.based):
(1 Blood Bank Blood Bank w/ Addt’l. Function
(-] Blood Collection Unit C1 Blood Station
Clinical Laboratory
Dental Laboratory
once

Dialysis Clinic
HIV Testing Laboratory
Hospital [ ] General [7] Level [4 Level2 CI Level3
[ ] 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

Cer rere
[ ]
[ ] Occupational Establishment Dental Clinic
[ ] Private School Dental Clinic
reer rer rrerr rir rerrrerirerrrererert eter rr rr rr Trt Trt rts
Type of Application for Change/s (in existing HF) [ Please check [V] appropriate box ].
Increase/Decrease in ABC from to Change in classification (function, institutional character)
Increase/Decrease in no. of
dialysis station Specify

|| from to
Change/Additional Equipment (including devices under FDA)
Specify
Increase/Decrease
No. of Unit/s from
in ambulance vehicle:
———— to
Type (Specify) from to

Change/Additional personnel Specify Hospital downgrading from —_____ to


Change in Name to
Change in service/s Specify
Others Specify
Additional service/s Specify

"Note: Please attach documentary requirements with change/s


Details of Change/s

Signature over printed name of Director/Owner

Recommendation: Date
For inspection
For submission of documents LC] Others Specify
For issuance of LTO/COA/COR/ATO

Recommended by: Approved by:


DOH-HFSRB-QOP-01-Form 2
Rev.:00

and
3/1/2019
Print Name Signature Page 1 of 1

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