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Department of Health
OFFICE OF THE SECRETARY
DEPARTMENT MEMORANDUM
No. 2019 - OU
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.
Accordingly, the following application forms shall be deemed superseded and obsolete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.
For compliance.
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
*
Name
Telephone No.:
DOH-HFSRB-QOP-01-Form’
of Health
HF Address
:
Status of Application:
RRP
Private
Institutional Character: [
[ ]
RERUN
[
[
]
]
Service/s:
Birthing Home
tick
1
Clinical Laboratory
Dental Laboratory
]
(J
No. &
[
Street
City/Municipality
:
Province
]
Fax No
New
colorectal surgery
(FJ generat surgery
[J ophthalmologic surgery
[
:
Date Issued
Barangay
Province
Renewal
]
License No.
R
boxes below and provide necessary documents.
E-mail Address:
DOH-Retained
[.) Cooperative
] Free-Standing
____E—SC«Vadidity
[]
of Health
HEALTH FACILITIES AND SERVICES REGULATORY BUREAU
District
(ABC)
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
i Rev:00 :
i
3/1/2019 |
Name and Signature of Applicant Date of Application i
settee Page 1of2.3
*
*
Acknowledgement
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
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.
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
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
Recommendation: Date
For inspection
For submission of documents LC] Others Specify
For issuance of LTO/COA/COR/ATO
and
3/1/2019
Print Name Signature Page 1 of 1