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Kultur Dokumente
Department of Health
HEALTH FACILITIES AND SERVICES REGULATORY BUREAU
Classification:
Ownership Function Service Capability
[ ] Government [ ] General [ ] Level 1
[ ] Private [ ] Specialty [ ] Level 2
[ ] Level 3
A B C
Documents Initial Renewal
Application Application
Required For All Hospitals
1. Hospital
1.1. Notarized duly accomplished Application for License to Operate a
Hospital (this form)
1.2. List of Personnel (use ANNEX A)
1.3. Photocopies of the following:
1.3.1. Proof of qualification
1.3.1.1. PRC ID
1.3.1.2. Certificate of Training
1.3.2 OSS License to Operate
1.4. List of Equipment/ Instrument (use ANNEX B)
1.5. Health Facility Geographic Form (Location Map)
1.6. Photographs of the exterior and interior of the hospital
1.7. Annual Hospital Statistical Report
2. Clinical Laboratory
2.1. List of Personnel (use ANNEX A)
2.2. Photocopies of the following:
2.2.1. Proof of qualification of pathologist and medical technologist
2.2.1.1. PRC ID
2.2.1.2. Specialty Board Certificate (for pathologist)
2.2.1.3. Certificate of Training
2.3. List of Equipment, Reagent, Laboratory Ware and Materials for
Specific Test (use ANNEX C)
2.4. Memorandum of Agreement, if not owned by the hospital
3. Pharmacy
3.1. List of Personnel (use ANNEX A)
3.2. Photocopies of the following:
3.2.1. Proof of qualification of pharmacist
3.2.1.1. PRC ID
3.2.1.2. Certificate of Training in Licensing of Drug
Establishments and Outlets
3.3. List of Products (use ANNEX D)
3.4. Memorandum of Agreement, if not owned by the hospital
4. Radiology
4.1. List of Diagnostic Radiology and Radiation Oncology Services by
Category (use ANNEX E)
4.2. List of Personnel for Diagnostic Radiology and Radiation Oncology
Services (use ANNEX F)
4.3. For diagnostic radiology services, photocopies of the following:
4.3.1. Proof of qualification of radiologist and radiologic/ x-ray
technologist
4.3.1.1. PRC ID
4.3.1.2. Specialty Board Certificate (for radiologist)
4.3.1.3. Certificate of Training
4.4. For radiation oncology services, photocopies of the following:
4.4.1. Proof of qualification of radiation oncologist/ medical
physicist/ radiotherapy technologist
4.4.1.1. PRC ID (for radiation oncologist and radiotherapy
technologist)
4.4.1.2. Specialty Board Certificate (for radiation oncologist)
Form-HOS-OSS-HOS-LTO-A
Revision:01
12/08/2014
Page 2 of 5
A B C
Documents Initial Renewal
Application Application
4.4.1.3. Masters Degree in Medical Physics (for medical
physicist)
4.4.1.4. Certificate of Training
4.5. List of X-ray Machines (use ANNEX G)
4.6. Acceptance/Performance Test Result for Computed Tomography and
Mammography x-ray machines
4.7. Photocopy of official receipt from PNRI for new film badge
subscription for one year
4.8. Photocopy of film badge personal dose evaluation reports within the
validity period of the hospital license
4.9. Certificate of compliance with pre-operational requirements for
medical linear accelerator facility
4.10. Facility report on the installation and commissioning of the equipment
duly signed by the facilitys qualified medical physicist and the
technical representative of the equipment manufacturer/supplier
4.11. Conformance testing report of the BHDT medical physics team on the
x-ray units in the medical linear accelerator facility
4.12. Quality audit report of the BHDT health physics team on the medical
linear accelerator facility
5. Dialysis Clinic
5.1. List of Personnel (use ANNEX A)
5.2. Photocopies of the following:
5.2.1. Proof of qualification of medical and paramedical staff
5.2.1.1. PRC ID
5.2.1.2. Certificate of Training
5.3. List of Equipment/ Instrument (use ANNEX B)
5.4. Manual of Operations/ SOP
5.5. Annual Summary Report of Patients Registered to the Renal Disease
Registry (Certificate of Compliance)
5.6. Documented Quality Assurance Program (QAP)
7. Blood Bank
7.1. List of Personnel (use ANNEX A)
7.2. Photocopies of the following:
7.2.1. Proof of qualification of medical technologist and donor
recruitment officer
7.2.1.1. PRC ID
7.2.1.2. Certificate of Training
7.3. List of Equipment, Laboratory Ware and Materials (use ANNEX H)
7.4. Certificate of Inclusion in the Official Blood Services Network of
NVBSP
7.5. List of Blood Stations and Blood Collection Units within the network
7.6. Documented Blood Transfusion Committee
Form-HOS-OSS-HOS-LTO-A
Revision:01
12/08/2014
Page 3 of 5
A B C
Documents Initial Renewal
Application Application
7.7. Annual Accomplishment Report using NVBSP Form
affidavit to attest to the completeness and truth of the foregoing information and the attached
documents and to the hospitals compliance with all standards and requirements for the
Registration and Initial/ Renewal of License to Operate a Hospital as set by the Department of
Health.
_____________________________
Signature
Before me, this _______ day of ______________ 2007 in the City/ Municipality of
instrument and they acknowledge to me that the same is their free act and deed.
_______________ 20___.
NOTARY PUBLIC
My Commission Expires
December 31, 20______