Republic of the Philippines

Department of Health

BUREAU OF HEALTH FACILITIES AND SERVICES

APPLICATION FOR LICENSE TO OPERATE

Name of Health Facility :
Address :
No. & Street

Barangay

City/Municipality

Province

Region

Type of Health Facility:

[ ]

[
[
[
[
[

]
]
]
]
]

[ ]
[ ]
[ ]

Ambulatory Surgical Clinic

Service/s:
colorectal surgery
pediatric surgery
general surgery
plastic and reconstructive surgery
ophthalmologic surgery
reproductive health surgery
oral and maxillo-facial surgery
thoracic surgery
orthopedic surgery
urologic surgery
otolaryngologic surgery
Blood Bank
Birthing Home
Clinical Laboratory
Dialysis Clinic
Hospital
Function:
[ ] General
Level 1
Level 2
Level 3
[ ] Specialty, Specify ___________________________________________________________
HIV Testing Laboratory
Infirmary
Psychiatric Care Facility
acute chronic
custodial

Telephone No.:

Fax No :

E-mail Address:

Head of the Facility :

*Chief of Hospital (for Hospitals):
Owner :
Classification According to:
Ownership :
[ ] Government
Institutional Character:
[ ] Hospital based
Status of Application :
[ ] Initial

[ ] Private
[ ] Non-hospital based
] Renewal
License No.
Validity

Authorized Bed Capacity (ABC) :

Please tick () the appropriate boxes below and provide necessary documents. Item shaded is not required.
Documents
1.

Acknowledgement (notarized)

2.

List of Personnel (use ANNEX A)

3.

List of Equipment/Instrument (use ANNEX B)

4.

List of Ancillary Services (ANNEX C), if applicable

5.

Application Form ( for Medical X-ray Facility)

6.

Application Form (for Hospital Pharmacy)

7.

Renewal

Location map of the health facility

8.

Photographs of the exterior and interior of the health facility

9.

Annual Statistical Report

10.

Initial

xxxxxxxxxx

Copy of Official Receipt (OR) for application fee

Note: Please refer to www.bhfs.doh.gov.ph. Application Form for other ancillary services

Form-HF-LTO-A
Revision: 00
06/06/2013
Page 1 of 5

Name and Signature of Applicant

Date of Application

ANNEX A
LIST OF PERSONNEL
Name of Health Facility:
Address of Health Facility :
Fill up all items by writing down the answer and/or putting a check on the appropriate boxes.

DEPARTMENT (if

hospital)

PRC
No.

(mo/date /yr)

Others, specify

POSITION

Temporary

NAME

Permanent

STATUS
Date
of
Birth

TRAINING

SIGNATURE

Use additional sheets when necessary

Prepared by: ___________________________________________

Form-HF-LTO-A
Revision:00
06/06/2013
Page 2 of 5

ANNEX B
LIST OF EQUIPMENT/INSTRUMENT
Name of Health Facility:
Address of Health Facility :
Fill up all items by writing down the answer and/or putting a check on the appropriate boxes.

ITEM

DATE
ACQUIRED

QTY

CONDITION
New

Serviceabl
e

REMARKS

Use additional sheets when necessary.

Form-HF-LTO-A
Revision:00
06/06/2013
Page 3 of 5

Prepared by: _________________________________________________

ANNEX C
LIST OF SERVICES IN A HOSPITAL
GENERAL
Clinical
Services
and
Facilities for
In-Patients

Ancillary
Services

LEVEL 1

LEVEL 3

[ ] Consulting Specialists in:

[ ] Medicine
[ ] Pediatrics
[ ] OB-GYNE
[ ] Surgery
[ ] Emergency and Out-patient Services
[ ] Isolation Facilities
[ ] Surgical/Maternity Facilities
[ ] Dental Clinic

[ ] Consulting Specialists in:

[ ] Medicine
[ ] Pediatrics
[ ] OB-GYNE
[ ] Surgery
[ ] Emergency and Out-patient Services
[ ] Isolation Facilities
[ ] Surgical/Maternity Facilities
[ ] Dental Clinic
[ ] Departmentalized Clinical Services
[ ] Respiratory Unit
[ ] General ICU
[ ] High Risk Pregnancy Unit
[ ] NICU

[ ] Secondary Clinical Laboratory

[ ] Tertiary Clinical Laboratory

[ ] Blood Station

[ ] Blood Station

[ ] Consulting Specialists in:

[ ] Medicine
[ ] Pediatrics
[ ] OB-GYNE
[ ] Surgery
[ ] Emergency and Out-patient Services
[ ] Isolation Facilities
[ ] Surgical/Maternity Services
[ ] Dental Clinic
[ ] Departmentalized Clinical Services
[ ] Respiratory Unit
[ ] General ICU
[ ] High Risk Pregnancy Unit
[ ] NICU
[ ] Teaching/Training w/ Accredited
Residency Training Program in:
[ ] Medicine
[ ] Pediatrics
[ ] OB-GYNE
[ ] Surgery
[ ] Physical Medicine and Rehabilitation
Unit
[ ] Ambulatory Surgical Clinic
[ ] Dialysis Clinic
[ ] Tertiary Laboratory w/
histopathology
[ ] Blood Bank

[ ] 1 Level X-ray

[ ] 2nd Level X-ray w/ mobile unit

[ ] 3rd Level X-ray

[ ] Pharmacy

[ ] Pharmacy

[ ] Pharmacy

[
[
[
[

[ ] Radiation Oncology
[ ] Conventional Radiation Therapy
[ ] Stereotactic Radiosurgery (SRS)
[ ] Intensity Modulated Radiation

[
[
[
[

st

Other
Ancillary
Services

LEVEL 2

] Specialized Diagnostic X-ray Services

] Computed Tomography
] Lithotripsy
] Cardiac Catheterization

[ ] Mammography
[ ] Bone Densitometry

Therapy (IMRT)
[ ] 3D Conformal Radiation Therapy

[ ] Digital Subtraction Angiography

[ ] Percutaneous Transluminal Angioplasty

[ ] Total Body Irradiation (TBI)

]
]
]
]

HIV Testing Laboratory

Laboratory for Drinking Water Analysis
Drug Testing Laboratory
others, specify

[ ] Tumor Localization and Simulation

Form-HF-LTO-A
Revision:00
06/06/2013
Page 4 of 5

Acknowledgement
REPUBLIC OF THE PHILIPPINES
CITY/ MUNICIPALITY OF

)
) S.S.

I,

,
Name

of legal age,

Civil Status

, a resident of
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 license to operate pursuant to
existing rules and regulations.

Signature

Before me, this ______ day of ____________________________ 2013 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.
PageNo.
BookNo.
Series of

NOTARY PUBLIC
My Commission Expires
Dec. 31, 20
Form-HF-LTO-A
Revision:00
06/06/2013
Page 5 of 5