Republic of the Philippines

Department of Health
HEALTH FACILITIES AND SERVICES REGULATORY BUREAU
DOH-HFSRB-QOP-01-Form 2
a
Date:
Name of Health Facility (HF)/Service Provider
HF Address :
No. & Street Barangay
District

City/Municipality Province
Region
HF Landline No. Mobile No. E-Mail Address
Owner

Latest LTO/COA/ATO No. Validity Period from to

Permit to Construct No. (if applicable) Date Issued:
Type of Health Facility/Service:
License to Operate:
[ ] Ambulatory Surgical Clinic [ ] Ambulance Service Provider
[ ] Birthing Home Ambulance unit/s approved: No. . Type
[ ] Blood Service Facility (Hosp.based):
Blood Bank Blood Bank w/ Addt’l. Function
Blood Collection Unit Blood Station
[ ] Clinical Laboratory
[ ] Dental Laboratory
[ ] Dialysis Clinic
[ ] HIV Testing Laboratory
[ ] Hospital [ ] General Level 1 Level 2 Level 3
[ ] Specialty, Specify ___________________________________________________________
[ ] Infirmary
[ ] Psychiatric Care Facility
Certificate of Accreditation: Certificate of Registration:
[ ] Blood Center [ ] Special Clinical Laboratory
[ ] Drug Abuse Treatment and Rehabilitation Center
[ ] Kidney Transplant Facility Authority to Operate:
[ ] Laboratory for Drinking Water Analysis [ ] Blood Collection Unit
[ ] Medical Facility for Overseas Workers and Seafarers [ ] Blood Station
[ ] Newborn Screening Center
[ ] Human Stem Cell & Cell-Based or Cellular Therapy

[ ] Occupational Establishment Dental Clinic

[ ] Private School Dental Clinic

Type of Application for Change/s (in existing HF) [ Please check [√ ] appropriate box ].
Increase/Decrease in ABC from to Change in classification (function, institutional character)
Increase/Decrease in no. of dialysis station Specify
from to
Change/Additional Equipment (including devices under FDA) Increase/Decrease in ambulance vehicle:
Specify No. of Unit/s from to
Type (Specify) from to

Change/Additional personnel Specify Hospital downgrading from to

Change in Name to
Change in service/s Specify
Others Specify
Additional service/s Specify

Note: Please attach documentary requirements with change/s

Details of Change/s

Signature over printed name of Director/Owner Date

Recommendation: Date_________
DOH-HFSRB-QOP-01-Form 2
For inspection Rev.:00
3/1/2019
Page 1 of 2
 For submission of documents Others Specify
For issuance of LTO/COA/COR/ATO

Recommended by: Approved by:

Print Name and Signature

DOH-HFSRB-QOP-01-Form 2
Rev.:00
3/1/2019
Page 2 of 2