Republic of the Philippines

PROVINCE OF MISAMIS OCCIDENTAL

Municipality of Baliangao
7211, Philippines
MUNICIPAL HEALTH OFFICE
baliangao_mho@yahoo.com
Hotline No. 0939-909-9411/0917-7027253

GUIDELINES ON THE USE OF LGU AMBULANCE

AUTHORIZED USE

1. Transfer of patient from the RHU to other health facility.

3. Transfer of patient from other health facility.
4. Transport of bedridden patient from the patient’s residence to other health facility.
5. Transport of bedridden patient from the hospital to the
6. Transport of bedridden patient from the hospital to the airport or seaport.
7. In instances where the patient for transfer died en-route to the referral hospital, the ambulance
can go back to the Calamba District Hospital in order for the IDH Doctor on duty to pronounce
the death of the patient or the ambulance can go to any nearby hospital for the pronouncement of
death. In the event that the patient was brought to other hospital, then the hospital ambulance is
no longer responsible in bringing back the patient’s dead body.
8. In special circumstances, when en-route to the hospital where the patient is being referred
either in Roxas or Iloilo, the patient died in the ambulance, as special consideration due to
distance, the ambulance vehicle may be used in transporting back the patient to Ibajay.
9. In special circumstances, for transport of the medical supplies and drugs and medicines that
are urgently needed by the hospital.
10. In exigency of service, for transport of hospital personnel from their residences when they
are urgently needed to report for duty especially during the occurrence of natural calamities,
disasters and other emergencies.

AMBULANCE FEE

1. No fees shall be collected from the patient and significant others.

2. Special consideration is given to most patients for transport from Baliangao to Calamba where
in the patient/ patient’s folks/representative .

However, for patient’s going to , the patient/patient’s folks/representative should pay the
corresponding ambulance rental to cover the fuel cost as well as the maintenance of the vehicle
as per Provincial Ordinance.
3. In cases where there are two or more patients who are transported at the same time, then the
ambulance fee shall be shared equally by the said patients.
3. Payment of ambulance fee:
During office hours (Mon – Sun, 8:00 AM – 12:00 NN, 1:00 PM – 5:00 PM)
 Payment should be given at the Administrative Office
 Official Receipt of the diesel fuel is given to the patient/patient’s
folks/representative in case of patient going to Kalibo and can be claimed
from the office the following day; a copy of the request for ambulance use
which serves as the provisional receipt will be given upon payment; this
payment will be used for the purchase of diesel fuel for the ambulance
 In cases of transport to Iloilo or Roxas, the Official Receipt of the hospital is
issued upon payment of ambulance rental
 Refueling of the ambulance shall be arranged by the Administrative Office

After office hours

 Payment should be given to the Nurse on duty and a copy of the request for
ambulance use which serves as the provisional receipt is issued
 Republic of the Philippines
PROVINCE OF MISAMIS OCCIDENTAL
Municipality of Baliangao
7211, Philippines
MUNICIPAL HEALTH OFFICE
baliangao_mho@yahoo.com
Hotline No. 0939-909-9411/0917-7027253

 Official Receipt as mentioned above can be claimed during office hours the
following day
 The ambulance driver is not authorized to transact for payment from the
patient, patient’s folks/representative. He is also not authorized to get the
payment from the Nurse on duty for the refueling of the ambulance. Payment
can only be given to him if with written instructions or verbal instructions
(personal or through telephone) from the Administrative Officer or the Chief
of Hospital.

PERSONS AUTHORIZED TO NOTIFY THE AMBULANCE DRIVER

1. During office hours (Mon – Sun, 8:00 AM – 12:00 NN, 1:00 PM – 5:00 PM)
 Administrative Office Personnel on duty

2. After office hours:

 Doctor on duty
 Nurse on duty
 Nursing attendant on duty
 Security guard on duty
 IW on duty

Important Note: The ambulance driver upon notification should be told of the reason for
transport and the severity of the patient’s condition.

AMBULANCE CALL

1. All calls to the ambulance driver for request for ambulance use should be recorded in the
logbook.

2. The time of call and the time the ambulance driver arrived should also be recorded in the
logbook.

3. In case the ambulance driver cannot be contacted after 3 to 5 attempts of calling, the hospital
personnel assigned should ask the Security Guard on duty or the IW on duty to go to the
residence of the ambulance driver and personally tell him of the need for ambulance use.

4. In case the ambulance driver is not around and cannot be contacted then the hospital
personnel assigned should notify Chola J. Magallon (PHN-NURSE-II) and she will be the one
to find a way for the patient’s transport.

5. In case the ambulance is not in Ibajay upon notification, the ambulance driver should inform
the hospital so that other mode of transport (use of other ambulance) can be arranged.

6. In case where the driver will not go back directly to the hospital upon going back from
transport of patient, the ambulance driver should notify the hospital of his whereabouts.

PROCEDURE

1. The Doctor on duty will make a Referral Slip and call the health facility where the patient is
being referred.
 Republic of the Philippines
PROVINCE OF MISAMIS OCCIDENTAL
Municipality of Baliangao
7211, Philippines
MUNICIPAL HEALTH OFFICE
baliangao_mho@yahoo.com
Hotline No. 0939-909-9411/0917-7027253

2. For patients for diagnostic purposes and own request for transfer, the Nurse on duty will ask
the patient’s folks/representative for the preferred ambulance to use (whether hospital
ambulance or municipal ambulance). If they prefer to use to municipal ambulance, the patient’s
folks/representative should be the one to ask the permission of the Municipal Mayor. If they
prefer to use the hospital ambulance, then it is the duty of the hospital personnel to notify the
ambulance driver of the hospital.
For emergency cases, the hospital ambulance is the preferred mode of transport of patients.

3. The Nurse on duty will fill-up the Request for Ambulance Use Form and instruct the patient’s
folks/representative to bring the said form together with the Referral Slip to the Administrative
Office.

4. The patient’s folks/representative will be asked to pay the corresponding amount for
ambulance fee.
In extreme emergency cases wherein due to the patient’s condition, immediate transfer is
needed and the patient/patient’s folks/representative cannot pay the ambulance fee, then the
patient’s folks/representative should sign a Promissory Note with the date of payment indicated.

5. The hospital personnel will notify the ambulance driver of the request for ambulance use.

6. Upon arrival to the hospital, the ambulance driver will prepare a Trip Ticket to be signed by
the Chief of Hospital or the Doctor on duty, Administrative Officer IV or the Administrative
Personnel on duty, and the patient’s folks/representative.

7. The Security Guard on duty should note on the logbook the time the Ambulance Driver
arrived in the hospital, the time the ambulance leave the hospital for transport of patient and the
time the ambulance returned to the hospital.

8. The Nurse on duty will call the Nursing Attendant on duty and the IW on duty and prepare
the patient for transfer from the ward/room to the ambulance vehicle.

9. Transport of patient to the referred facility.

10. In case where the patient who is referred to Kalibo is immediately referred to Iloilo or
Roxas, the ambulance driver should notify the hospital of the said plan. The ambulance driver
should also inform the patient’s folks/representative of the corresponding ambulance fee. If the
payment is made, he should turn-over the payment to the Cashier upon his arrival to the hospital
during office hours or on the following day if after office hours.

AMBULANCE CONDUCTION

1. Conduction of patients for transfer by the hospital personnel (doctors, nurses, nursing
attendants, or midwife) is allowed in the following cases:
a. Emergency cases as defined below
b. For diagnostic purposes where a conducting nurse is specifically requested by the
diagnostic center being referred to

2. Conduction should be authorized by the Chief of Hospital or the doctor on duty and the Chief
Nurse or the nurse on duty. A travel order should be issued for the hospital personnel who will
 Republic of the Philippines
PROVINCE OF MISAMIS OCCIDENTAL
Municipality of Baliangao
7211, Philippines
MUNICIPAL HEALTH OFFICE
baliangao_mho@yahoo.com
Hotline No. 0939-909-9411/0917-7027253

be conducting and should be recommended by the Chief Nurse or the nurse on duty and
approved by the Chief of Hospital or the doctor on duty.

3. Conduction of patients during emergency cases mentioned above should be done by the
hospital personnel (doctor, nurse, nursing attendant, midwife) on duty. In cases where there is
only one doctor, one nurse and one nursing attendant or midwife who are on duty, then the
nurse on duty should look for the one who is off duty that is available who will conduct the
patient. In such case, the patient/patient’s folks/representative cannot demand for conduction
by the on-duty personnel since there are more patients who needed care who will be left in the
hospital as compared to only one patient for conduction. In cases where the nurse on duty
cannot find anyone who will conduct the patient, then the patient’s folks/ representative will be
the one to find the one who will conduct the patient on the ambulance. In cases where
ambulance conduction by a health personnel is advised and no one is available to conduct then
the patient’s folks/representative should sign a waiver where the transport of the patient to
other health facility is without the company of qualified health personnel.

4. The patient/patient’s folks/representative should pay the following conduction fee in lieu of
the medical services given to the patient during transport: (Subject to the Governor’s Approval
& SP Resolution???)
 Ibajay to Kalibo
Doctor P500
Nurse 250
Nursing Attendant/Midwife 200
 Ibajay to Iloilo
Doctor P5000
Nurse 2500
Nursing Attendant/Midwife 2000
 Ibajay to Roxas
Doctor P4000
Nurse 2000
Nursing Attendant/Midwife 1500
 Conduction fee to other areas should be agreed by both the hospital personnel
concerned and the patient/patient’s folks/representative.
 The above fees apply to the hospital personnel who are off duty and may apply
also to on duty personnel as agreed upon by both parties.
 The patient/patient’s folks/representative will not be given an official receipt for
the medical services given during conduction since the said service fee serves as the
professional fee of the health personnel who will render the service.

COMPLAINTS

1. Complaints regarding the ambulance and the ambulance driver should be made in writing
and address to the Chief of Hospital through the Administrative Officer IV.

2. Complaints should be recorded in the logbook and should be acted upon immediately.

3. Complaints aired over the radio should be answered after thorough investigation and data
gathering.
 Republic of the Philippines
PROVINCE OF MISAMIS OCCIDENTAL
Municipality of Baliangao
7211, Philippines
MUNICIPAL HEALTH OFFICE
baliangao_mho@yahoo.com
Hotline No. 0939-909-9411/0917-7027253

DEFINITION OF TERM

Emergency Cases:
The hospital considers the following cases as emergency which may warrant transfer of
patient upon the discretion of the attending physician or the doctor on duty:
1. Trauma cases
 With head injury and neurologic deficits
 With multiple injuries
 With fractures, especially open fractures
 With spinal cord injury
 Stab wounds/Hacked wounds
 Gunshot wounds
2. OB/Gyne cases
 OB patients(nulligravid or multigravid) in labor or PROM
 Pre-eclampsia or hypertensive OB patients
 Patients with severe vaginal bleeding
 Patients with ectopic pregnancy
3. Surgical cases
 Acute abdomen
 Acute appendicitis
 Acute cholecystitis with cholelithiases
 Incarcerated Hernia
4. Medical cases
 Severe Respiratory Distress
 Neurologic cases
 Stroke (GCS Score < 10)
 Seizure Disorder
 Acute Myocardial Infarction
 Severe GI Bleeding
 Poisoning
 Dengue Hemorrhagic Fever Stages 3 and 4
5. Other cases as determined by the Attending Physician or the Doctor on duty

Prepared by:

Dr. Mary Jane S. Sualog Mrs. Luzvilla D. Ascaño Mr. Rex S. Robles
Medical Specialist I Chief Nurse Administrative Officer IV

Noted by:

Dr. Mary Jean A. Gelito

OIC – Chief of Hospital
 Republic of the Philippines
PROVINCE OF MISAMIS OCCIDENTAL
Municipality of Baliangao
7211, Philippines
MUNICIPAL HEALTH OFFICE
baliangao_mho@yahoo.com
Hotline No. 0939-909-9411/0917-7027253

Recommending Approval:

Mr. Rex Victor B. Consemino

PGADH, EEDD

Approved by:

HON. CARLITO S. MARQUEZ

Provincial Governor