Republic of the Philippines

Department of Health
OFFICE OF THE SECRETARY

January 4, 2019

DEPARTMENT MEMORANDUM
No.
”3’0056

FOR : HEALTH FACILITIES AND SERVICES REGULATORYBUREAU

(HFSRB) CON CERNED PERSONNEL. DIRECTORS OF CENTERS
FOR HEALTH DEVELOPMENT1CHD [, DOH-CHD-REGULATION
LICENSING, AND ENFORCEMENT DIVISION gflEDz CHIEFS,
DOH-ATTACHED AGENCIES, AND OTHERS CONCERNED

SUBJECT : “Instructions in the Preparation of Permit to Construct, License to

Operate, Certificate of Accreditation,Authority to Operate, Certificate
of Registration, Remote Collection Permit for General Clinical Laboratory
(RCP-CL), and Recognition Certificates for Health Facilities”

In View of the recent amendments vis-a-vis on the regulation of health facilities, particularly the
preparation of issuance of authorization (license/accreditation), the existing memorandum dated
December 21, 2017 is hereby revised to update important details that shall be reflected in the
templates.

These particulars were stipulated in the following administrative issuances namely: Department Order
No. 2018-0301 dated August 28, 2018 under Annex B. DOH Functional Management Teams for the
Implementation of the FOURmula One Plus for Health Strategic Framework; Administrative Order
2018-0016 dated June 4, 2018 under Section V.A.10.c Revised Guidelines in the Implementation of
the One—Stop Shop Licensing System; Administrative Order 2018-0001 dated January 28, 2018 under
Section VI.B.1-2. Revised Rules and Regulation Governing the Licensure of Land Ambulances and
Ambulance Service Providers.

Attached is the instructions for the preparation of such issuance of authorization and sample templates
for the use of HFSRB concerned personnel and DOH-CHD-RLED.

Effective February 15, 2019, the revised templates shall be implemented for the renewal and initial
applications.

Please be guided accordingly.

By Authority of the Secretary of Health:

[A
ENRLIQ\U§D.
ROLAN DOMINGO, M.D., DPBO
Undersecretary of Health
Health Regulation Team

Building 1, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila 0 Trunk Line 651-7800 Direct Line: 711-9501
Fax: 743-1829; 743-1786 0 URL: http://wwwdoh.govph; e-mail: osec doll. ov. 11
 “I Republic of the Philippines
Department of Health
HEALTH FACILITIES AND SERVICES REGULATORY BUREAU

Instructions in the Preparation of Permit to Construct, License to Operate, Certificate of

Accreditation, Authority to Operate, Certificate of Registration, and Recognized
Laboratories for Health Facilities and Services
A. License to Operate/Certificate of Accreditation/Authorityto OperateICertificateof Registration:
1. Only the following health facilities and services shall be issued License to Operate, Certificate of
Accreditation, Authority to Operate, Certificate of Registration:
1.1 Ambulance Service Provider
1.2 Ambulatory Surgical Clinic
1.3 Birthing Home
1.4 Blood Bank
1.5 Blood Center
1.6 Blood Collection Unit
1.7 Blood Station
1.8 Clinical Laboratory- General
1.9 Special Clinical Laboratory
1.10 Dental Clinic- Occupational, Private School
1.11 Dental Laboratory
1.12 Dialysis Clinic
1. 13 Drug Abuse Treatment and Rehabilitation Center (DATRC) - Residential, Non-Residential
1.14 Drug Testing Laboratory (system generated)
1. 15 HIV Testing Laboratory
1. 16 Hospital
1. 17 Human Stem Cell/Cellular Therapy Facility
1 18 Infirmary
1. 19 Kidney Transplant Facility
1. 20 Laboratory for Drinking Water Analysis
1.21 Medical Facility for Overseas Work Applicant (MFOWS)
1. 22 Newborn Screening Center
1. 23 Psychiatric Care Facility— Acute Chronic, Custodial

2. License to Operate (LTO), Certificate of Accreditation(COA), Authority to Operate(ATO), and

Certificate of Registration(COR) shall not be processed and issued without the filled-out Assessment
Tool and Evaluation Report ( both initial and renewal HF application) of Licensing Officers and the
signature of the approving authority from the Health Facilities and Services (HFSRB) or DOH—Center
for Health Development and/or Food and Drug Administration (FDA) Regional Field Office (RFO)
-—

Center for Device Regulation, Radiation Health and Research (when applicable).

3. An alphanumeric code, shall be assigned to each LTO/COA/ATO/COR approved. The code shall
compose of five (5) parts:
3.1 The first part is a two (2) digit number which stands for the region number
(see Annex A Column 5);
3.2 The second part is a four(4) digit number which shall be numbered in sequence.
3.3 The third part is a two (2) to four (4) digit number which represents year of start of validity
and end of validity period.
Only a two (2) digit number shall be used if the start and end of validity period is on the same
ear.
Ell'he
3.4 fourth part is a one (1) to three (3) letter digit code or two (2) digit alphanumeric code (for
hospitals) which represents the type of facility. (see Annex A Column 2)
3.5 The fifth part is a one (1) digit number which is the type of ownership. Government owned is
equal to 1 and private owned is equal to 2 (See Annex A Column 6).

Example of license numbering:

Region-SequentialNumbering yearly-year start of validity and end of validity- Facility Code-ownership
13 - 0042 -1719 -LW -2

Page 1 of 6
 The assigned code shall be the license or accreditation number of the facility for new, a change of
ownership, transfer of site or upgrading of level of hospital. The license/accreditation number
shall remain the same regardless of changes applied until the validity period expires.

InSpecial Clinical Laboratory, the registration number shall be issued once as permanent COR.
changes on the service capability, the latest date of revision shall be reflected beside it in
If with
an open close parenthesis and in smaller italics font (size 8).

The font styles in each type of template shall be followed. (Please see sample templates.)
Font size can be changed if the space is insufficient. e.g. (other services offered).
The official color of DOH and/or DOH-Center for Health Development logo shall be followed.

Information that shall be reflected in the LTO/COA/ATO/COR shall depend on the type of health
facility. These are the following:
a) Owner
b) Operated/Managed by
c) Name of facility (in bold font)
d) Type of facility
e) Location
f) Service capability
9) Classification
h) Authorized Bed Capacity (ABC)
i) Authorized Dialysis Station
j) Authorized Ambulance Unit, Type of ambulance, Plate No. or Conduction Sticker(CS) No.,
Certificate of Registration (CR) No.
k) Other service/s offered
The above specifications shall also be applied for One-Stop Shop issuance of
license/accreditation certificates (where applicable).
Note: Plate No. or Conduction Sticker (CS) No., Certificate of Registration (CR) No. and
type of ambulance shall be reflected under Registered Ambulance Unit/s in
Ambulance Service Provider LTO

The ancillary services containing mandatory licensing requirements for Levels 1 to 3 General
Hospitals shall not be reflected in the template. The same also applies to non-hospital-based
Medical Facility for Overseas Workers and Seafarers (MFOWS).

Only the Other Services Offered which are above the minimum required, shall be reflected in the
LTO/COA. This is to eliminate redundant information, while easily differentiates the classifications of
health facilities and the additional services offered.

For other type of health facilities like Blood Service Facilities (Blood Bank, Blood Center, Blood
Collection Unit, Blood Station), Laboratory for Drinking Water Analysis, Human Stem Cell/Cellular
Therapy Facility and Special Clinical Laboratory, the basic services offered shall be indicated in the
LTO/COA/COR. It shall also specify the different tests provided by the health facility as stated in their
respective administrative issuances.
10. Updated Log Sheets of health facilities shall be prepared for other detailed information needed to
support the issuance of the license/accreditation certificates.

11. If there are application for changes in ABC, dialysis station, ambulance unit, service capability, the
latest date of revision shall be reflected beside it in an open close parenthesis and in smaller
italics font (size 8).

For a change of name, the latest date of issue/approval shall be reflected in the log sheet of each
type of HF including the latest name of the facility to record the history of change/revision.
12. Only hospitals have automatic renewal of LTD, but it shall not be processed without the submitted
accomplished application form and complete documentary requirements. Desk evaluation of
Licensing Officers/technicalstaff shall be done to support the issuance of LTD.

Page 2 of 6
 t

3. Certificate of Need (CON):

1. Only general hospital shall be issued Certificate of Need.

2. Certificate of Need (CON) shall not be processed and issued without the filled-out Evaluation Tool
and/or Additional Criteria for Concurrent Evaluation of more than one Application of the members
of the CON Committee. The Chairperson of the CON Committee shall affix his/her signature in the
tool.

3. The Director of the Center for Health Development shall sign the CON.

4. A code shall be assigned to an approved CON. Whether it is paper- based or in electronic format, the
certificate has two (2) parts:

4.1 The first part is a four (4) digit number which stands for the year when it shall be issued and
followed by a number in sequence starting from ‘01. The sequential numbering shall start from
‘

01 yearly.
Example of CON Code:
CON No. 2019-01

4.2 If there
is a request for an extension of validity date, an alphabet code shall be added to the
CON number that was already issued.
Example of CON Code:
CON No. 2019-01A

5. Information that shall be reflected in the CON are the following:

a) Name of facility (in bold font)
b) Location
c) Level of Hospital
d) Proposed Number of Beds
6) Date issued (mm/dd/yy)
f) Validity Period of six (6) months from start to end (see sample template)

C. Permit to Construct (PTC):

1. Only the following health facilities and services shall be issued Permit to Construct:

1.1 Ambulatory Surgical Clinic

1.2 Birthing Home
1.3 Dialysis Clinic
1.4 Drug Testing Laboratory (Free Standing)
1.5 Drug Abuse Treatment and RehabilitationCenter (DATRC)
1.5.1 Residential
1.5.2 Non-Residential
1.6 Hospital
1.7 Infirmary
1.8 Medical Facility for Overseas Work Applicant (MFOWS)
1.9 Psychiatric Care Facility
1.9.1 Acute-Chronic
1.9.2 Custodial

Permit to Construct (PTC) shall not be processed and issued withOut the filled-out Checklist for
Review of Floor Plan or Evaluation Report of Health Facility Evaluation and Review Committee
(HFERC) members and the signature of the approving authority from HFSRB and/or DOH-Center
for Health Development.
3. A code shall be assigned to an approved PTC. Whether it is paper— based or in electronic format,
the PTC code has two (2) parts:

Page 3 of 6
 ‘ .
I

3.1 The first part is a two (2) digit number which stands for the year when it shall be issued and
followed by a number in sequence starting from 0001. The sequential numbering shall start from
0001 yearly.
Example of PTC Code: PTC No. 19-0001

3.2 Date issued shall be reflected at the bottom of the permit in mm/dd/yy format.
Example Date Issued: January 3, 2019
:

4. The Scope of Work reflects the coverage of the project that will be implemented by the facility.
The type of facility shall also be specified.

5. The Terms and Conditions is composed of eight (8) categories pertaining to the duties and
responsibilities that should be undertaken by the facility owner related to the approved scope of the
project.

6. If there are applications for change/s in ownership, ABC, Dialysis station, another PTC shall be
issued. There shall be no another issuance of PTC if only change in business name.

License to Operate, Certificate of Accreditation, Authority to Operate, Certificate of Registration,

Permits to Construct:
1. The official type of paper for the LTO/COA/ATO/COR is the A4 size parchment paper.

2. A corresponding abbreviated name of issuing office shall be printed as watermark in the

license/certificate.

All certificates shall reflect the corresponding administrative issuances for each type of facility at the
bottom.

The gold dry seal/dry seal (whichever is applicable) shall be placed at the lower left side of the
license/certificate

There shall be two (2) copies for each certificate (LTO, COA, ATO, COR, PTC). Both copies shall
bear the signature of the Director IV of HFSRB or Director III of HFSRB, or DOH-Center for Health
Development Director. Only one(1) copy shall be signed by the authority recommending the
approval.

In case a license/certificate was already released/out to the client, and typographical error was made
or detected, it shall be recalled, marked as cancelled and countersigned by the Process Owner.
Another copy of the license/certificate shall be prepared without change in the code or numbering.

The retention of license/certificate shall be in accordance with the revised DOH Retention and
Disposition Schedule whether it is a paper-based or electronicallygenerated.

D. Remote Collection Permit for General Clinical Laboratory (RCP-CL)

1. Remote Collection Permit for General Clinical Laboratory (RCP-CL) shall not be processed and
issued without the complete Evaluation Report and approved application for RCP-CL signed by
the approving authority from HFSRB or DOH-Center for Health Development.

RCP-CL numbering code has two (2) parts which composed of the complete date approved
(yy/mm/dd) and a four (4) digit sequential numbering. The sequential numbering shall start from
0001 yearly.

Example of RCP-CL Code:

(yy/mm/dd) sequential numbering
190103 0001

Page 4 of 6
 Date issued shall be reflected at the bottom of the permit in mm/dd/yy format.
Example: Date Issued: 1/3/2019

3. The Scope of Work shall reflect the name , address of the company, and date where the remote
collection shall be conducted.

4. Terms and Conditions pertains to the duties and responsibilities as well as other requirements
that should be undertaken by the facility owner regarding remote collection.

E. Certificate of Recognition for Laboratory for Dialysis Water Analysis:

1. Certificate of Recognition for Laboratory for Dialysis Water Analysis shall not be processed and
issued without a completely filled-out Assessment Tool and Evaluation Report of Licensing Officers
and the signature of the approving authority of HFSRB.

2. Information that shall be reflected in the certificate are the name of owner, validity of accreditation,
the service/s offered whether bacteriological, physical and chemical analysis. The other tests being
offered by the health facility shall also be specified.

Prepared by:

ATTY. ODEt-HLORES
Chief, egulatory Compliance and Enforcement Division

/
Approved y:

V " l/
ATTY. ICOLAS B. LUT Olll,CESOIII
Director IV

Page 5 of 6
 Annex A- Specifications in the Assignment of Codes/Numbering for License to Operate (LTO),
Certificate of Accreditation(COA),Authority to Operate(ATO), Certificate of
Registration(COR) for Health Facilities, Permit to Construct, Remote Collection Permit
for General Clinical Laboratory (RCP-CL)

1 2 3 4 5 6
FACILITY TYPE OF ISSUING AUTHORITY
FACILITY CODE ISSUANCE REGION Ownership
INITIAL RENEWAL
(new. with 01 01 llocos 1= govt
Chang?” 02 02 Cagayan Valley
Ambulance Service Provider ASP LTO HFSRB/ HFSRB / 03 03 Central Luzon 2=private
CHD CHD 4A 4A CALABARZON
Acute Chronic Psychiatric Care AP LTO HFSRB CHD 4B 4B M'MAROPA
05 05 BlCOl
Facility .

Ambulatory Surgical Clinic AS LTO HFSRB g: 367 ggrftEZjnvlgggggs

Blood Center BC LTO HFSRB 08 08 Eastern Visayas

Blood Collection Unit BCU ATO CHD 09 09 Zamboanga
Blood Station BS ATO HFSRB/CHD Peninsula
Clinical Laboratory CL LTO HFSRB (if CHD 10 10 Northern
CHD Mindanao
owned) / 11 11 Southern
Mindanao
CHD
12 12
Special Clinical Laboratory SCL COR(no HFSRB gfgggfi
renewal) (Central
Custodial Psychiatric Care CP LTO HFSRB CHD Mindanao)
Facility 13 13 NCR
Dialysis Clinic DC LTO HFSRB/CHD 14 14 CAR
15 15 ARMM
Drug Abuse Treatment and DR COA HFSRB
16 CARAGA
16
Rehabilitation Center
Drug Testing Laboratory DT COA HFSRB
PRC-DTS
Occupational Dental Clinic D0 COA (no HFSRB
renewal)
Private School Dental Clinic DS COA(no HFSRB
renewal)
Dental Laboratory DL LTO CHD
Hospital H1, LTO HFSRB CHD
H2113 (Level 1)
Kidney Transplant Unit KT COA HFSRB
Laboratory for Drinking Water LW COA HFSRB CHD
Analysis
Medical Facility for Overseas MF COA HFSRB
Workers and Seafarers
Newborn Screening Center NS COA HFSRB
Primary Care Facility - Infirmary I LTO CHD
Primary Care Facility Birthing
— BH LTO CHD
Home
Stem Cell Facility SCF COA HFSRB
Permit to Construct PTC HFSRB
Remote Collection Permitfor RCP-CL RCP-CL HFSRB/CHD
General Clinical Laboratory
rev Dec2018 (deleted NIR region, add CHD in Blood Station, RCP-CL)

Page 6 of 6
 Republic of the Philippines
DEPARTMENT OF HEALTH
CALABARZON CENTER FOR HEALTH DEVELOPMENT

Sample template draftJan2019

CON No. 2018-03

Mongolian Baiti 33

CERTIFICATE OF NEED
is hereby granted to

MTB Hosp1tal
Baras, Rizal

(Candara 12) (Candara 13)

Level of Hospital : Level 1

Proposed Number of Beds : 99

Date Issued : August 20, 2018
Validity Period : 20 August 2018 to 26 February 2019

Mongolian Baiti 35
By Authority of the Secretary of Health:

(Arial Unicode 14)

EDUARDO C. JANAIRO, M.D.,MPH, CESOIII
Director lV

This certificate of need is subject to suspension or revocation if the facility is found vloIating A0 2006-0004 and related issuances.
 Republic of the Philippines
DEPARTMENT OF HEALTH
HEALTH FACILITIES AND SERVICES REGULATORY BUREAU
Revised 2018changed signatory

PERMIT TO CONSTRUCT
CambriA 12 arial 12
Owner : PRT Hospital Inc.
Name of Facility : PRT HOSPITAL OF MANDAUE, INC.
Location : Campos Avenue, Mandaue City, Cebu

Scope of Work : For the expansion/renovation of Cebu Cancer Institute (with Pedia
Chemotherapy Room for 12 pediatric patients and Short Infusion
Room for 8 adult patients).

Terms and Conditions:

1. That the construction, alteration, expansion or renovation of a hospital or other health facility is
implemented in accordance with:
1.1 Floor plans prepared by a duly licensedArchitect and/or Civil Engineer and approved by the Health
Facilities and Services Regulatory Bureau;

1.2. Architecturaland engineeringdrawings (based on approved floor plans by the Health Facilities and Services
Regulatory Bureau), specifications, building permit and fire safety permit prepared by a duly licensed Architect
and/or Civil Engineerand approved by the Office of the Building official and the Bureau of Fire Protection
in the locality;

2. That the permit to construct and approved floor plans comprise observance of appropriate professional
practices, prescribed functional relationships and applicable codes;
3. That the permit to construct and approved floor plans are availablefor ready reference at the construction
site;

4. That the permit to construct is considered lapsed and fee paid is forfeitedwhen the work authorized by
the permit does not commence within 365 days from date of issuance, or is abandoned during the period
specified; in which case, another application shall be filed;

5. That the submission of progress report/status on the construction both for new and existing health facility is
required every six (6) months until project completion.
6. That any addition and/ or alteration of scope of work shall be reported immediately to the Health Facilities
and Services Regulatory Bureau for appropriate action;

7. That any unauthorized deviation from approved floor plans or any violation of the above condition, will be
sufficient ground for the imposition of sanctions as based from the provisions of Administrative Order No.
2016-0042.

8. Inspection of the facility is necessary prior to the operation, utilization or usage of the approved scope of
work.

ATTY. NICOLAS B. LUTERO III, CESO III

Director IV
PTC No. 18-0200
Date Issued: April 26, 2018 (size 8)
 Republic of the Philippines (arial12)
DEPARTMENT OF HEALTH (arial 13)
Metro Manila Center for Health Developmentrariai 14)

Sample template draftlan2019

LICENSE TO OPERATE
(century golhic l l) {century goihic l3) watermark (bookman oldstyle 54)

Owner Local Government Unit

Operated/Managed
by (if applicable)
Name of Hospital : GHI HOSPITAL
Type of Facility Hospital
Location : Muzones 81., Bgy. San Juan, Pateros,
Metro Manila
Service Capability Level 1

Classification : General
Authorized Bed Capacity : 20 (10/07/2018)
Authorized Ambulance Unit 1, Type l, Plate No. XXXX, CR No. xxxx
License Number : lB—éél—lS—Hi—l
Validity of License : 26 May 20l8 — 31 December 2018
Other Service Offered:

Dialysis Clinic (6 stations)

By Authority of the Secretary of Health: (arial Unicode 11)

DRY SEAL ARIEL I. VALENCIA, M.D.(arial Unicode 14

Director |V(arial Unicode 13)

This license is renewable annually and subject to suspension or revocation if the hospital is found violating RA 4226 and related
issuances. (cambria 8)
 Republic of the Philippines (arial12)
DEPARTMENT OF HEALTH (arial13)
HEALTH FACILITIES AND SERVICES REGULATORY BUREAU(ariaI14)

Sample template Rev Dec2018

LICENSE TO OPERATEWW,
(century gothic I l) (century gothic )3) watermark (bookman oldstyle 54)
Owner : Philippine General Hospital
Operated/Managed
by (if applicable) :

Name of Facility : UP-PHILIPPINE GENERAL HOSPITAL

Type of Facility : Hospital
Location : Taft Avenue, Ermita, Manila, Metro Manila
Service Capability : Level 3
Classification : General
Authorized Bed Capacity : l334 (10/13/2018)
Authorized Dialysis Station : 4
Authorized Ambulance Unit : I, Type l, Plate No. xxxx, CR No. xxxx
License Number : 13-296-18-H3—l
Validity of License : Oi January 2018 — 31 December 2018
Other Services Offered:
HIV Testing Laboratory Specialized Diagnostic X—ray Services:
Laboratory for Drinking Water Analysis Computed Tomography name of owner
-bacteriologica| Mammography) name of owner
Digital Subtraction Angiography) name of owner
Cardiac Catheterization (i )) name of owner
Percutaneous Transluminal
Angioplasties) name of owner
Bone Densitometry) name of owner
Tumor Localization &Simulation) name of owner
Cardiac Catheterization (2)) name of owner
Interventional Radiology
Dental

By Authority of the Secretary of Health: (arial Unicode 11)

DRY SEAL ATTY. NICOLAS B. LUTERO III, CESO "I(arial

Unicode 14 Director |V(ariai Unicode 13)

This license is renewable annually and subject to suspension or revocation if the hospital is found violating RA 4226 and related
issuances. (camhria 8]
 Republic of the Philippines (arial12)
DEPARTMENT OF HEALTH (arial13)

Sample template draftlan2019

LICENSE TO OPERATE (century schoolbook 38)

(book Aniiguo l 1) (book Anfiguo l3) watermark (bookman oldstyle 54)

Owner
Operated / Managed
by (if applicable) 2

Name of Dental Laboratory : DHRAM DENTAL LABORATORY

Location : 1311 Rm. 520 Scout Ramos, Sta. Cruz, Manila
Metro Manila
Service Capability : Removable Prostheses Services
License Number : 13-09-1517—DL-2
Validity of License : 02 March 2015 - 31 December 2017

By Authority of the Secretary of Health: (century schoolbook 12)

DRY SEAL CORAZON I. FLORES, M.D., MPH, CESO IV (century

schoolbook 16)
Director IV(century schoolbook l/l)

years and subject to suspension or revocation if the facility is found violating Provision
This accreditation is renewable every three(3)
ofSection3 ofPD Na. 1542 and related issuances. (cambria 8)
 Republic of the Philippines (arial12)
DEPARTMENT OF HEALTH (arial13)
HEALTH FACILITIES AND SERVICES REGULATORY BUREAU(ariaI14)

Sample template Rev Dec 2018

LICENSE TO OPERATE (arial rounded MT 801(144)

(combrio 12) (combrio I3) watermark (bookman oldstyle 54)

Owner : DOH-Center for Health Development-Bicol
Operated/Managed
by (if applicable) :

Name of Facility : REGIONAL HEALTH LABORATORY N0. V

Type of Facility : Clinical Laboratory
Location : Legazpi City, Albay
Classification : Free Standing, Limited
License Number : 05-0013-17-CL-1
Validity of License : 16 January 2017 — 31 December 2017
Service:

Limited—emeticbacteriology

By Authority of the Secretary of Health: (arial rounded ml12)

DRY SEAL ATTY. NICOLAS B. LUTERO Ill, CESO llllaria.

rounded mi18

Director lV(arial rounded ml 14)

This license is renewable annually and subject to suspensionor revocation if the facility is found violating RA 4688/A0 2007-002 7
and related issuances. cambria 8}
 Republic of the Philippines (arial12)
DEPARTMENT OF HEALTH (arial13)
CALABARZON CENTER FOR HEALTH DEVELOPMENTWMI 14)

Sample template draftlan2019

LICENSE TO OPERATE (Georgia 41)

(book Aniiguo 12) (book oniiguo 13) watermark (bookman oldstyle 54)

Owner
Operated/ Managed
by (if applicable) I

Name of Facility : BCD BIRTHING HOME

Type of Facility : Birthing Home
Location : 81 Said Street, Tulay, Cavite
Authorized Bed Capacity : 03
License Number : 4A-084-17-BH—1
Validity of License : 25 May 2017 — 31 December 2017
Other Services Offered:

Diagnostic X—ray Services (Level 1)

Ambulance:
1 unit, Type 1, Plate No. xxx, CR N0. xxx

By Authority ofthe Secretary of Health: (georgia 11)

DRY SEAL EDUARDO C. JANAIRO, M.D.,MPHM,CESO III

(georgia 16)DII'eCtOI' IV (georgia 14)

This license is renewable annually and subject to suspension or revocation if the facility is found violating A0 2012-0012 and related
issuances..(cambria 8)
 Republic of the Philippines (arial12)
DEPARTMENT OF HEALTH (ariai 13)
ELGCOS CENTER FOR HEALTH IEVELGPMENT (arial 14)
Sample template draftlan2019

LICENSE TO OPERATE
(arial 42)

(cambria heading l2) {combrio heoding l3) watermark (bookman oldstyle 54)
Owner : Dr. Buhawin Signal
Operated/ Managed
by (if applicable) .

Name of Facility : YZA CLINIC AND HOSPITAL

Type of Facility : Infirmary
Location : 25 Sabarte, Ilocos Norte
Authorized Bed Capacity : 22
Authorized Ambulance Unit : 1, Type 1, Plate No. xxx, CR No. xxxx
License Number : 01-0004-17-1-2
Validity of License : 01 January 2017 - 31 December 2017
Other Service Offered:

Diagnostic X—ray Services (Level 1)

By Authority of the Secretary of Health: (arial12)

DRY SEAL VALERIANO V. LOPEZ, M.D.,MHA.MPH,CESO |V

(aria! 16 )

DireCtOr |V(arial14)

This license is renewable annually and subject to suspension or revocation if the facility is foundviolating A0 2012-0012 and related
issuances. (cambria 8)
 Republic of the Philippines (ariai12)
DEPARTMENT OF HEALTH (arial 13)
HEALTH FACILITIES AND SERVICES REGULATORY BUREAU (ariai
14)
Sample template draftlanZOlEl

LICENSE TO OPERATENW)
(ceniury goihic l l) (ceniury goihic 13) watermark (bookman oldstyle 54)
Owner : Exequiel Ace
Operaied/Managed
by (if applicable) 2

Name of Facilily : JTV HEALTH SERVICES

Type of Faciliiy : Acuie Chronic Psychiairic Care Faciliiy
Loca’rion : Sio. Cris’io, Pampanga
Authorized Bed Capaciiy : 122
License Number : 03-00054 7—AP-2
Validity of License : 07 January 2017 ~— 31 December 20] 7

By Authority of the Secretary of Health: (arial Unicode 11)

DRY SEAL ATTY. NICOLAS B. LUTERO III, CESO "I(arial Unicode 14)

Director IV(arial Unicode 13)

This license is renewable annually and subject to suspension or revocation if the facility is found violating A0 2012-0012 and related
issuances. (cambria 8)
 Republic of the Philippines (arial12)
DEPARTMENT OF HEALTH (arial 13)
HEALTH FACILITIES AND SERVICES REGULATORY BUREAU (arial
14)
Sample template draftlan2019

LICENSE TO OPERATEWEWZ)

(century go’rhic l 1) (cenlury gOIhIC I3) watermark (hookman oldstyle 54)

Owner :
Segunda Begay
Opera’red/Managed
byapplicable)
(if

Name of Facilily PQR HOME CARE FACILITY

§

Type of Facilily : Cus’rodial Psychia’rric Care Faciliiy

Location : 78 Langaka Sireei, Pasig Ciiy, Melro Manila
Authorized Bed Capacity 15
License Number : 13-0009-1 7—C P—2

Validiiy of License : 23 January 2017 — 3i December 201 7

By Authority of the Secretary of Health: (arial Unicode 11)

DRY SEAL ATTY. NICOLAS B. LUTERO III, CESO III(arial Unicode 14)

Director IV(arial Unicode 13)

This license is renewable annual-1y and subject to suspension or revocation ii the facITIty is found violating A0 2012-0012 and related
issuances. (cambria 8)
 Republic of the Philippines
DEPARTMENT OF HEALTH
HEALTH FACILITIES AND SERVICES REGULATORY BUREAU

Sample template draftlan2019

Arial Unicode MS 44

LICENSE TO OPERATE
Century gothic 1 1
Century gothic l3
Owner :
Department of Health
Name of Facility 2
DAVAO BLOOD CENTER
Type of Facility : Blood Center
Location : DOH Compound, J.P. Laurel Ave., Davao City
License Number : l I-OO8—1820—BC—l

Validity of License : Oi January 2018 — 31 December 2020

Services:
Century gothic lO
Advocacy and promotion of voluntary blood donation and healthy lifestyle;
Recruitment, retention and care of voluntary blood donors;
Collection of blood (mobile or facility—based) from qualified voluntary blood donors;
Newewpr
Conduct health education and counselling;
Testing of units of blood for Transfusion-Transmitted Infections (TTIs);
Processing and provision of blood components;
Storage, issuance, transport and distribution of units of whole blood and/or blood products to
hospitals and other health facilities.

Arial Unicode l 1

By Authority of the Secretary of Health:

ATTY. NICOLAS B. LUTERO III, CESO |l| Arial Unicode 14

Director IV Arial Unicode 13

”This license is renewable every three (3) years and subject to suspension or revocation if the facmty is found violating any provisions of
'
A0 2008-0008 r(cambria 8)
 Republic of the Philippines (arial12)
- DEPARTMENT OF HEALTH (arial 13) 1

HEALTH FACILITIES AND SERVICES REGULATORY BUREAU(ariaI14)

Sample template draftJan2019

LICENSE TO OPERATE
(arial Unicode MS 42)

(century goihic i 1) (century goihic 13) watermark (bookman oldstyle 54)

Owner VWX Medical inc.
.

Name of Health Service Provider : VWX 911 MEDICAL INC.

Type of Health Service : Ambulance Service
Locafion : 25 Las Pinas City, MeiroManila
institutional Character Non-institution based
Authorized Ambulance Units IO
License Number : 13-0003-1719—ASP-2
Validity of License : 01 July 2017—31 December 2019
Registered Ambulance Unit/s : Plate No. C R NO. Typeiceniury goihic8)
I 301 06 215185736 ii

ACS9251 210600515
070103 210594753
I 301 O4 302246103
AAD8868 229188374
AAD9685 226451514
OV31 60 272562253
070103 277219515 (10/25/2018) (century goihic 8)
277219482 (ii/l2/20i8)
CS NO.
MS 4826 303456263 (9/27/2018)

By Authority of the Secretary of Health:

ATTY. NICOLAS B. LUTERO III, CESOIII

Director IV

This license is renewable every three (3] years and subject to suspension or revocation if the service provider is found violating A0 2016-0029
and related issuances. (cambria 8)
 Republic of the Philippines (arial12)
DEPARTMENT OF HEALTH (arial 13)
HEALTH FACILITIES AND SERVICES REGULATORY BUREAU(arial14)

Sample template draftJan2019

CERTIFICATE OF ACCREDITATION
(cambria 33)

(oriol I2) (Ciriol 13) watermark (bookman oldstyle 54)

Owner : MNO Cooperative

Operated/Managed
by (if applicable) :

Name of Facility : MNO LABORATORY SERVICE

COOPERATIVE
Type of Facility :
Laboratory for Drinking Water Analysis
Location :
Dimagiba Heights, Quezon City
Metro Manila
Accreditation Number : 4A-300—1719-LW-1
Validity of Accreditation : 01 January 2017 — 31 December 2019
Service:

Chemical Analysis
Tests:
1.
2.

By Authority of the Secretary of Health: (cambria 12)

DRY SEAL ATTY. NICOLAS B. LUTERO III, CESO 111(cambri316)

Director IV(cambria 14.)

This accreditation is renewable every three(3) years and subject to suspension or revocation if the facility ls found violating .40 2006-0024
and related issuances. (cambria 8)
 Republic of the Philippines (arial12)
, DEPARTMENT OF HEALTH (arial13)
v HEALTH FACILITIES AND SERVICES REGULATORY BUREAU(arial14)

NO REVISION

CERTIFICATE OF ACCREDITATION r
(cambria 33)

(CiriGI I2) (Griol I3) watermark (bookman oldstyle 54)

Owner
Operated/Managed
by (if applicable) :

Name of Facility : NSTV MFG. COMPANY

Type of Facility :
Occupational Establishment Dental Clinic
Location Masamyo Street, Leyte
Accreditation Number : 08—05-03—DO-2
Date Issued : 03 May 2005

By Authority of the Secretary of Health: (cambria 12)

DRY SEAL ATTY. NICOLAS B. LUTERO III, CESO 111(cambria 16)

Director IV(cambria l4)

This accreditation is subject to suspension or revocation if the facility is found violating A0 No. 3 5., 1 998 pursuant to Book 1 V of the Labor
Code of the Philippines and related issuanccs. {cambria 8)
 Republic of the Philippines (arial12)
DEPARTMENT OF HEALTH (arial 13)
HEALTH FACILITIES AND SERVICES REGULATORY BUREAU(arial14)

NO REVISION

CERTIFICATE OF ACCREDITATION
(cambria 33)

(ariol l2) (OFIOI 13) watermark (bookman oldstyle 54)

Owner
Operated/Managed
by (if applicable)
Name of Facility HPQ COLLEGE
Type of Facility Private School Dental Clinic
Location Dalandanan, Valenzuela, Metro Manila
Accreditation Number 13-030—03-DS-2
Date Issued 13 October 2003

By Authority of the Secretary of Health: [cambria 12)

DRY SEAL ATTY. NICOLAS B. LUTERO III, CESO 111(cambria 16)

Director IV[cambria 14-)

This accreditation is subject to suspension or revocation if the facility is found violating A0 No. 4 s., 1 998 pursuant to RA 951
and related issuances. (cambria 8)
 Republic of the Philippines
DEPARTMENT OF HEALTH
HEALTH FACILITIES AND SERVICES REGULATORY BUREAU

Sample template draftlan2019

CERTIFICATE OF ACCREDITATION

Owner : Dr. Nuestra Aprova

Name of Facility : APROVA MEDICAL AND DIAGNOSTIC
LABORATORY
Type of Facility : Medical Facility for Overseas Workers and Seafarers
Locafion . MBA Bldg., Poblacion, lloilo City
Classification :
Regular Land-based and Seafarers Medical Facility
Accreditation Number : 06—009-1921- MF-2
Validity of Accreditation : 01 January 2019- 31 December 2021

By Authority of the Secretary of Health:

ATTY. NICOLAS B. LUTERO, CESO III

Director IV

This accreditation is renewable ever three (3) years and subject to suspension or revocation if the facility is found violating A0 2013-0006
and related issuances.
 Republic of the Philippines
.
DEPARTMENT OF HEALTH
HEALTH FACILITIES AND SERVICES REGULATORY BUREAU

Revised Dec2018

CERTIFICATE OF ACCREDITATION
(cambria 33)

Ariol 12 Ariol l3

Owner :
Department of Health
Name of Facility : R0 Xl OUTPATIENT AND AFTERCARE
CENTER FOR DRUG DEPENDENTS
Type of Facility : Drug Abuse Treatment & Rehabilitation Center
Location : DOH-RO XI Compound, J.P. Laurel Ave., Bajada,
Davao City, Davao del Sur
Classification : Free Standing, Non-Residential
Accreditation Number : 11-007-16-DR-1
Validity of Accreditation : 22 February 2016 — 31 December 2018

Cambria 12
By Authority of the Secretary of Health:

Cambria 16
ATTY. NICOLAS B. LUTERO III, CESO III
Director IV Cambria 16

This accreditation is renewable every three (3) years and subject to suspension or revocation if the facility is found violating RA 9165
and related issuances. (cambria 8)
 Republic of the Philippines (ariaI12)
DEPARTMENT OF HEALTH (arial13)
WESTERN VISAYAS CENTER FGR HEALTH DEVELQPMENWariaI 13)
Revised Dec2018

AUTHORITY To OPERATE
(century gothic I) I
(century gothic I3) )
watermark [bookman oldstyle 54)

Owner : Philippine Red Cross- Copiz Chopter

Operated/Managed
by (if applicable) :

Nome of Facility : PHILIPPINE RED CROSS- ILOILO CHAPTER

Type of Facility : Blood Station
Location : Provincial Pork, Roxcls City, Copiz
Authorization Number : 06—007-1 719-BS-2
Validity : 21 October 20I 7 — 3i December 2OI 9

By Authority of the Secretary of Health: (arial11)

MARLYN W. CONVOCAR, M.D. (ariai 16)

Director IV (ariaI14)

This authority to operate is renewable every three (3) years and subject to suspension or revocation if the facility is found violating
RA 7719 and related issuances. (cambria 3}
 Republic of the Philippines (arial12)
DEPARTMENT OF HEALTH (arial13)
CENTRAL VISAYAS CES‘éTER FOR HEALTH BEVELQPMENT (arial 13)

Revised Dec2018

AUTHORITY To OPERATE
(century goihic I I) (century goihic I3) ) watermark (bookman oldstyle 54)

Owner : Philippine Red Cross— Copiz Chapter

Operated/Managed
by (if applicable) :

Nome of Facility : PHILIPPINE RED CROSS- CEBU CHAPTER

Type of Facility : Blood Collection Unit
Location : Cebu City, Cebu
Authorization Number : 07-0054 7I 9-BCU-2
Validity : 22 October 201 7 — 3i December 201 9

By Authority of the Secretary of Health: (arial 11)

DRY SEAL JAIME S. BERNADAS, M.D.,MGM,CESO III (arial

16)
Director IV (arial 14)

This authority to operate is renewable every three (3) years and subject to suspension or revocation if the facility is found violating
RA 771 9 and related issuances. (cambria 8)
 Republic of the Philippines (arial12)
DEPARTMENT OF HEALTH (arial 13)
WESTERN VESAYAS CENTER FQR HEALTH EEVELQPMENT (arial 13)

revised Dec2018

AUTHORITY TO OPERATE
(century goihic i I) (century go’rhlc 13) ) watermark (bookman oldstyle 54)

Owner : Philippine Red Cross— Copiz Chdp’rer

Operated/Managed
by (if applicable) :

Name of Focilily : PHILIPPINE RED CROSS- CAPIZ CHAPTER

Type of Faciliiy : Blood Collection Unit, Blood Sidiion
Locolion : Provinciol Pork, Roxos Ciiy, Copiz
Auihorizon‘ion Number : 06-001 -1 7i 9-BCU-BS—2
Volidily : 21 Ociober 2017 - 31 December 2019

By Authority of the Secretary of Health: (arial11)

DRY SEAL MARLYN W. CONVOCAR, M.D. MPH, CESO "I(arial16)

Director IV (arial14) ,

This authority to operate is renewable every three (3] years and subject to suspension or revocation If the facility is found violating
RA 7719 and related issuances. (cambria 8)
 Republic of the Philippines
DEPARTMENT OF HEALTH
HEALTH FACILITIES AND SERVICES REGULATORY BUREAU

No revision
Mongolian Baiti 35

CERTIFICATE OF REGISTRATION
(Candara 12) (Candara13)
Owner : lN-VlTRO CENTER, INC.
Name of Facility : lN-VITRO CENTER
Type of Facility : Special Clinical Laboratory
Location : G/F, HRZ Bldg., Poblacion, Davao City
Davao Del Sur
Registration Number : 11—OOZ—18-SCL—2

Date issued : August 20, 2018

Service Capability : “Assisted Reproductive Technology” through ln-Vitro
Fertilization (with or without) or Intracytoplasmic
Sperm injection ( lVF or ICSI)

Mongolian Baiti 35
By Authority of the Secretary of Health:

(Arial Unicode 14)

ATTY. NICOLAS B. LUTERO |||, CESO Ill

Director IV

This certificate ofregistration is subject to suspension or revocation if the facility is found violating RA 4688 /A0 200 7-0027
and related issuances.(cambria 8)
 Republic of the Philippines
DEPARTMENT OF HEALTH
HEALTH FACILITIES AND SERVICES REGULATORY BUREAU

Sample template drafiJanZOlQ

CERTIFICATE OF RECOGNITION Book Antigua 28

LABORATORY FOR DIALYSIS WATER ANALYSIS

Book Antigua 20

is hereby granted to

AQUI CORPORATION mm
45 Auction St., Manda/uyong City aria113

Century golhic ii cenlury goihic 12

Owner : AQUI CORPORATION

Validity of Accrediiaiion : 03 March 2016 - 31 December 2018

Service:

Chemical Analysis Physical Analysis Bacteriological Analysis

1. Arsenic (AS) {size 9) l.Turbidiiy l. MTFT
2. Cadmium (Col) 2. Total Dissolved Solid 2. HPC
3. Lead (Pb)
4. Nitrate (N03)
5. Mercury

Book Antigua 12
By Authority of the Secretary of Health:

Book Antigua 16
ATTY. NICOLAS B. LUTERO III, CESO III
Director IV

This accreditation is renewable every three(3) years and subject to suspension or revocation if the facility is found violating A0 2013-0003
and related issuances. Cambria 8
 Republic of the Philippines
Department of Health
Manila
Approved New template

RCP-CL No.: 1806150001

REMOTE COLLECTION PERMIT FOR GENERAL CLINICAL LABORATORY

Arial 12 all caps
is hereby granted to
Arial 12 all caps
MIDZ DIAGNOSTIC AND OUTPATIENT CENTER-times new roman 16

47 Escalante Blvd., Phase 3, Davao City, Davao Del SurArial12

DOH License No.11-095-18-CL—2 Arial12

Pursuant to Department Circular No. 2018-0223 dated May 29, 2018, titled “Guidelines in Securing
the Remote Collection Permit for Clinical Laboratories”
Arial 11
Arial 11
Scope of Work:
Place: Davao Oriental Mfg. Center, Mati, Davao Oriental
Date: July 27, 2018 to August 12, 2018

Terms and Conditions:

1 Remote collection facility should have a proper area for specimen collection.
2. Only employed Registered Medical Technologists (RMTs) of the abovementioned clinical
laboratory shall be allowed to collect blood samples/specimens.
No testing or processing of specimens shall be done in the temporary collection facility.
mew
. The activity at the remote facility shall only last for four (4) to six (6) hours.
Specimens should be properly handled and transported,
5.1 Samples for routine urinalysis and routine fecalysis shall be stored at refrigerated
temperature within one (1) hour from the time of collection.
5.2 The serum from blood samples for chemistry must be separated within four (4) hours from
the time of collection.
6. The collection site shall be located within the same region, at a maximum of (100) kilometre
radius, from the address of DOH licensed clinical laboratory.
7. A copy of this RCP-CL shall be posted in conspicuous area of the remote collection facility.
8. This permit shall be valid only for two (2) weeks from the date of issuance.

ATTY. NICOLAS B. LUTERO Ill, CESO III Arial 12

Director IV Arial 11

Date issued: 7/27/2018

 Republic f the Philippines
Depart ent of Health
HEALTH FACILITIES AND S RVICES REGULATORY BUREAU

MEMORANDUM

DATE :
December 21, 2017

TO : HFSRB Staff, DOH-RegiOnal Offices -Regulation Compliance and

Enforcement Division (RUED), and Process Owners}

V
It!
(P
:4"
a,“cm
tilt
,. 215': _,
,.
:P

'34
x iCOLAé
FROM : ATT Y. B. LQ‘I‘ERO til, CESO It!
Director IV 4‘
,

SUBJECT : Instructions in the Preparation of License to Operat , Certificate of

Accreditation, Authority to Operate, Certificate of R gistration for Health
Facilities

The HFSRB as the regulatory body which sets standards'fo'FL regulation of health facilities
has revised the templates for all certificates to be issued by this Office including! all regions.
Attached instructions, annex, templates of the certificates, and log sheet shall be implemented
effective January 3, 2018.

For compliance.

Thank you.
 Republic of the Philippines
Department of Health
HEALTH FACILITIES AND SERVICES REGULATORiY BUREAU

“.4

Instructions in the Preparation of to Operate. Certificate of Accreditation,

Liceniestration for Health
Authority to Operate, Certificate of Facilities and Services
Reg
1. Only the following health facilities and services shall be issued License to Operate, Certificate of
Accreditation, Authority to Operate, Certificate of Registration: ' -

1.1 Ambulatory Surgical Clinic

1.2 Birthing Home
1.3 Blood Bank
1.4 Blood Collection Unit
1.5 Blood Station
1.6 Clinical Laboratory
1.7 Dental Laboratory
1,8 Dialysis Clinic
1.9 Drug Abuse Treatment and Rehabilitation Center (DATRC)
1.10 HlV Testing Laboratory
1.11 Hospital
1.12 lnfirmary
1.13 Kidney Trans plant Facility .

1.14 Medical Facility for Overseas Work Applicant (MFOWS)

1.15 Newborn Screening Center
1.16 Psychiatric Care Facility

e
-

1.17 Stem Cell Facility '

1.18 Special Clinical Laboratory " ..

’

.
,

1.19 Ambulance Service Provider '

,2. No License to Operate (LTO), Certificate of Accreditation(COA), Authority to Operate(ATO), and

Certificate of Registration(COR) shall be made and issued without the attachment of filled-out
Assessment Tool or Evaluation of Licensing Officers or approving persnnnei of HFSRB, FDA, and
DOH-Regional Offices.

3. Each approved application of health facility or service has assigned license/accreditation

certificate/authority to operate/certificate of ilegistration code. This code has 'five(5) parts which
composed of the following:
3.1 The first part is a two (2) digit number which stands for the region number
i

(see Annex A Column 5);

3.2 The second part is a sequential numbering which is a four(4) digit number starts from 0001.
3.3 The third part is a two (2) to four (4) dig number which represents year of start of validity
'

and end of validity period. Only a two %) digit number shall be used; if year of start and end of
validity period is the same (e.g. Januar 1, 2017 to December 31, 2017).
3.4 The fourth part is a three(3) digit alphanumericcode which represents type of facility (see
Annex A Column 2) .

3.5 The fifth part is a one(1) digit number which is the type of ownership. Government owned code
is equal to 1 and private owned code is ebual to 2 (See Annex A Column 6).

(e.g.) Region-Sequential Numbering yearly-year start of validityand end of validity— FacilityCode-ownership

13 - 0042 ~1113 -LW -2

4. The assignment of code will start if health facility (HF) or service is new or there is a change of owner.
The iicense/accreditationcertificates code shall remain the same regardless of changes applied
until such validity period will expire or renew.

5. The font styles in each type of template shat" be followed (indicated in the template). Font size can
be changed if the space is not enough like in Other Service/s Offered category.
The official color of DOH and/or Regional Offline logo shall be followed.
U 6.- Particulars that shall be reflected in the template shall depend upon on the type of facility such the
following: '
as
i ;

a) Owner .1
b) Operated/Managed by
c) Name of facility
d) Type of facility
e) Location
f) Service capability
9') Classification
h) Authorized bed capacity
i) Number of dialysis station
j) Number of ambulance unit
k) Other service/s offered
The above specifications shall also e applied for One-Stop Shop issuance of
license/accreditation certificates (w .
re applicable).
7. The basic mandatory requirements shall be reflected in the template to highlight most important
details. Only the Other Services Offered shno; ll be reflected.
Another AnnexesILog Sheets shall be
prepared and attached for the updated other particulars needed to support the details in the
license/accreditation certificate issued. 4

e.g. ambulance vehicle plate number

ambulance vehicle certificate of registration
Use A4 size paper or parchment paper as this official type of paper for the certificate.

A corresponding abbreviated name of issuing office shall be printed as watermark in the certificate.

10. Allcertificates shall reflect the corresponding administrative issuancesffor'each

type of facility at the
bottom. v.

11. The gold dry seal shall be placed at the lower left side of the certificate.

12. There shall be two (2) copies for each certifi ate (LTO, COA. ATO, COR); Both copies shall bear the
signature of the head of the respective D H-Regional Offices or the Director ill or Director N of
HFSRB. Only one( 1) copy shall be signed by the authority
recommending the approval.
13. Incase a license/certificate was already released/out to the client, and typographical error was
made or detected, it shall be recalled, cancelled. and printed without change in the code or number.
The recalled copy shall be marked as cancelled and countersigned by the Process Owner.

14. The retention of certificates shall be in accordance to the revised DOH Retention
and Disposition
Schedule whether it is a paper-based or electronically generated.

Approvedfiby: M,
/ii"
r"
»
“Maura."

ATl'Y. *3!) [32“‘rtones

Chief, Regulatory Compliance and Enforcement Division
December 21, 2017

Noted byzy"
.1'
a" . -‘-,
v 4
9 r, a. .31
iJ',‘t...
g £51“ v
flow“ ‘
3
ATTY. .N’lCOLASI B. LUngRO llliCESO Ill
Director IV
December .21, .2017