Republic of the Philippines

PHILIPPINE HEALTH INSURANCE CORPORATION

ACCREDITATION DEPARTMENT
12th Floor City State Centre Bldg., 709 Shaw Blvd. Oranbo, Pasig City
Tel No. 637-62-65 Trunk line 637-99-99 loc 1215, 1216, Telefax. 637-25-27
E-mail: Accre@philhealth.gov.ph

CHECKLIST OF REQUIREMENTS FOR HOSPITAL ACCREDITATION

( SECONDARY )
NAME OF HOSPITAL:____________________________________________________________
ADDRESS: _____________________________________________________________________

________ 1.
________ 2.
________ 3.
________ 4.
________ 5.

PhilHealth application form properly accomplished.

Duly notarized Warranties of Accreditation.
DOH License issued 2002.
PHA / PHAP Certificate of Membership issued 2002.
List of functional / serviceable equipment signed by Medical
Director / Administrator (Annex A).
________ 6. List of current hospital's bed rates (Annex B).
________ 7. List of current hospital service charges (Annex C).
________ 8. Ancillary Licenses issued / revalidated 2001 - 2002.
a.) Laboratory License
b.) X-ray License
c.) Hospital Pharmacy License
________ 9. Complete / departmentalized list of hospital staff with respective
designation indicating position as full time or part time and training if
there are any ( Annex D ).
________10. Training certificate in General Surgery of Resident Surgeon for
Secondary hospitals.
________11. Accreditation fee of P2,000.00 for Secondary Hospitals by postal
money order payable to Philippine Health Insurance Corporation
or cash paid directly to cashier and / or photocopy of OR from PRO.
________12. Therapeutics Committee members and activities.
________13. Ongoing Quality Assurance Program.
________14. Photocopy of Remittance Form I ( RF1 ) for the last quarter.
________15. Sanitary permit of Dietary Section for the year 2002.
________16. Updated Health Certificate of Dietary personnel.
________17. Fire Safety Permit for 2002.
Additional Requirements for Initial Accreditation:
________ 1. Current photographs of hospital faade, ER, Laboratory, Pharmacy,
X-ray, Nursery, DR, OR, Recovery Room, ICU, Isolation Room, CR,
Records, Business Office, Nurses Station, CSS and other available
hospital facilities.
________ 2. Current photograph of complete hospital staff.
________ 3. Current standard operating procedures.
________ 4. SEC License / DTI certificate / CDA certificate.
________ 5. DOH licenses of three (3) previous successive years or Mayor's Permit.
DOCUMENTS SUBMITTED TO PRO:
TO PHILHEALTH CENTRAL OFFICE:
Region: ___________________________
Date Received: ______________________
Date Received: _____________________
Received By: ________________________
Received By: _______________________
Received and Assessed By: ____________
Date Refiled: _______________________
PRO staff are advised to strictly indicate the above data.

Republic of the Philippines

PHILIPPINE HEALTH INSURANCE CORPORATION

ACCREDITATION DEPARTMENT
12th Floor City State Centre Bldg., 709 Shaw Blvd. Oranbo, Pasig City
Tel No. 637-62-65 Trunk line 637-99-99 loc 1215, 1216, Telefax. 637-25-27
E-mail: Accre@philhealth.gov.ph
PhilHealth ACCREDITATION FORM
APPLICATION FOR ACCREDITATION ( SECONDARY )

_____________________, 20___

THE PRESIDENT
Philippine Health Insurance Corporation
Pasig City, Philippines
SIR :
I, _______________________________, Filipino of legal age, _____________________ with address
(Position / Designation)

at _________________________________ and the duly authorized representative to act for and in

behalf of _________________________________________, hereby applies for accreditation under
( Health Care Institution )

Sec. 16 L of R.A. 7875 and its Implementing Rules and Regulations thereto. For this purpose, I hereby
submit the following pertinent information and documentary requirements.
PART I - GENERAL INFORMATION
Name of Hospital : _______________________________________________________________________
Complete Address : ____________________________________________ Postal Code : ______________
PhilHealth Code No. : _______________ Tel No.: ___________________ Fax No.: _________________
Date established : ________________________ Date of Last Accreditation : ______________________
Chief / Medical Director : _________________________

Administrator : ________________________

DOH License No. ________________ valid from __________ to __________ issued on __________, 20__
Ownership / Management
( )
Single Proprietorship
( )
Corporation
( )
National Government
Others, specify _________________________________
A.

( )
( )
( )

Cooperative
Foundation
Local Government

(
(
(

Old structure
Renovated
New structure

PHYSICAL PLANT & ENVIRONMENT

1.

2.

Building
( )
Concrete
( )
Semi-concrete
( )
Wood

)
)
)

Sanitation and Safety Standard

a.
Water supply
__________________________________
b.
Electric Power __________________________________
Stand by generator
( ) Yes
( ) No
c.
Sewage Disposal
Solid waste by
________________________________

Liquid waste by _________________________________

Pathological waste by _____________________________
d.
e.
f.

Fire escape
(
Fire extinguisher (
Toilet facilites
(

)
)
)

Yes
Yes
Yes

(
(
(

)
)
)

No
No
No

3.

Has there been any change in ownership or management ?

( ) Yes
( ) No
If yes, when ? _____________________________

4.

Has the Health Care Institution transferred to another location ?

( ) Yes
( ) No
If yes, where ? _____________________________
( complete address )
Has there been any change in category or authorized bed capacity since last accreditation
?
( ) Yes
( ) No If yes, when ? ________________ What ? _____________

5.

B.

HOSPITAL BEDS

C.

MANPOWER COMPLEMENT
1.

Submit complete list of hospital's bed per room and current rates.
( See Annex B )

Medical Service
a. Consultants:

( Indicate the Number )

Full Time

Part Time

Visiting

________
________
________
________
________
________
________
________
________
________

________
________
________
________
________
________
________
________
________
________

_______
_______
_______
_______
_______
_______
_______
_______
_______
_______

2. Nursing Service
a. Registered Nurse
b. Registered Midwives
c. Nursing Aides

________
________
________

________
________
________

_______
_______
_______

3. Pharmacist

________

________

_______

4. Laboratory & X-ray

a. Medical Technologist
b. X-ray Technologist

________
________

________
________

_______
_______

5. Dentist
6. Dietitian
7. Administrative Service
8. Others

________
________
________
________

________
________
________
________

_______
_______
_______
_______

General Surgery
Sub-surgical Specialty
OB-Gyn
Pediatrics
Internal Medicine
Pathology
Radiology
Dental
Others ____________________
b. Residents

NOTE : Submit complete list of hospital personnel. ( See Annex D )

D.

CLINICAL FACILITIES
(
(
(

)
)
)

Emergency room
Doctor's / Consultation office
Clinical laboratory
Laboratory Lic. No. __________ valid from _______________ to ______________
X-ray facility
X-ray Lic. No. _____________ valid from _______________ to ______________

(
(
(
(
(
(
(
(
(
(
(

)
)
)
)
)
)
)
)
)
)
)

Pharmacy Lic. No. ____________ valid from __________ to ______________

Dental room
Drug room
Labor room
Delivery room
Nursery room :
No. of Bassinet / s _____ No. of Incubator / s _______
Operating room :
Minor OR _______
Major OR _______
Recovery room
Medical Records room
Dietary room
Others, please specify _________________________________________
Submit complete list of existing functional or serviceable equipment under
each facility.
( Please see Annex A )

E.

EQUIPMENT

F.

CLINICAL SERVICE
(
(
(
(
(

G.

General Medicine
General Surgery
Orthopedic Surgery
Opthalmology
Otolaryngology

(
(
(
(
(

)
)
)
)
)

Anesthesia
OB-Gyn
Pediatrics
Dermatology
Others, specify _______________

RECORDS
(

Case
No.

)
)
)
)
)

Admission
Date &
Time

(
(

)
)

Admission & discharge records

[ ] Prescribed logbook ( Follow PhilHealth Cir.
[
No. 56 s.1999, No. 38 s.2000 & No. 7 s.2002 )
Name of
Patient

Age

)
Case
No.

(
(
(

)
)
)

Membership

Admitting
Diagnosis

Attending
Physician

Name of
Patient

Age

Sex

Type of
Examination

Date of
Examination

Name of
Patient

Age

Sex

Type of
Examination

Date of
Examination

Disposition

OR logbook
Name of
Patient

Age

Sex

Membership

Admitting
Diagnosis

Procedure
Done

OPD logbook
Outpatient surgical logbook
Mandatory monthly hospital reports

H. QUALITY ASSURANCE PROGRAM OF THE INSTITUTION

1.
2.
3.
4.
5.

Final
Diagnosis

X-ray logbook
Case
No.

Address

Computerized

Patient's chart
Laboratory logbook
Case
No.

Sex

Plan
Mission and Vision
Personnel Responsible for the Program
Activities
Minutes of Meeting

Surgeon

Date of
Operation

Disposition
Date &
Time