Republic of the Philippines
Department of Health
HEALTH FACILITIES AND SERVICES REGULATORY BUREAU
DOH-HFSRB-QOP-01-Form1
Name of Health Facility (HF) or Service Provider :
HF Address :
No. & Street Barangay
District
City/Municipality Province
Region
Telephone No.: Fax No : E-mail Address:
Head of the Facility/Medical Director :
Owner :
Classification According to:
Ownership : [ ] Government Province Dist. City. Mun. DOH-Retained University Others, Specify
[ ] Private Corporation Partnership Proprietorship Cooperative Foundation
Institutional Character: [ ] Institution-based [ ] Non Institution-based [ ] Free-Standing
Status of Application : [ ] New [ ] Renewal
License No. Validity
Permit to Construct No. (If applicable). Date Issued________ Authorized Bed Capacity (ABC) :
Instruction: Please tick () the appropriate boxes below and provide necessary documents.
LICENSE TO OPERATE:
[ ] Ambulatory Surgical Clinic
Service/s: colorectal surgery otolaryngologic surgery
general surgery pediatric surgery
ophthalmologic surgery plastic and reconstructive surgery
oral and maxillo-facial surgery reproductive health surgery
orthopedic surgery thoracic surgery
urologic surgery
[ ] Birthing Home
[ ] Blood Service Facility: Blood Bank Blood Bank w/ Addt’l. Function
Blood Collection Unit (Hosp-based) Blood Station (Hosp-based)
[ ] Clinical Laboratory
[ ] Dental Laboratory
[ ] Dialysis Clinic
[ ] HIV Testing Laboratory
[ ] Hospital
Function: [ ] General Level 1 Level 2 Level 3
[ ] Specialty, Specify _______________________________________________
[ ] Infirmary
[ ] Psychiatric Care Facility Acute chronic Custodial
[ ] Ambulance Service Provider No. of Ambulance Unit: Type I Type II
CERTIFICATE OF ACCREDITATION:
[ ] Drug Abuse Treatment and Rehabilitation Center Residential Non-Residential
[ ] Dental Clinic Occupational Establishment Private School
[ ] Human Stem Cell and Cell-Based or Cellular Therapy Facility
[ ] Kidney Transplant Unit
[ ] Laboratory for Drinking Water Analysis Bacteriological Chemical Physical
[ ] Medical Facility for Overseas Work Applicants Regular Medical Facility
Special Seafarer’s Med. Fac. Special Land-based Med. Fac.
[ ] Newborn Screening Center
AUTHORITY TO OPERATE (For Free Standing)
[ ] 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 of Health Facility: XXXXXXX
2.1 DTI/SEC/CDA Registration including Articles of Incorporation/Cooperation and By-Laws
2.2 Enabling Act/ LGU Resolution (for government health facility) XXXXXXX
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) XXXXXXX
DOH-HFSRB-QOP-01 Form1
Rev:00
Note: Please refer to [Link]. for other details of the requirements. 3/1/2019
Page 1 of 2
Name and Signature of Applicant Date of Application
Acknowledgement
REPUBLIC OF THE PHILIPPINES ) CITY/
MUNICIPALITY OF ) S.S.
I, , , of legal age, , a resident of
Name Civil Status Age
, after having been sworn in accordance with law
Address
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 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, I 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
Page 2 of 2
