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Annexb PDR-HF-230804 Fillable
Annexb PDR-HF-230804 Fillable
INSTRUCTIONS
TYPE OF TRANSACTION:
1. All information should be written in UPPER CASE/ CAPITAL LETTERS.
2. All fields are mandatory unless indicated otherwise. If the information is not applicable, ☐ Initial
3.
write “N/A.”
For the Latitude and Longitude fields in Section No. 2 (Mailing/Billing Address), kindly provide the
☐ Renewal
official geographic coordinates used in the DOH Health Facility Geographic Form. ☐ Re-accreditation
4. For the name of the Head of Facility (HoF) in Section No. 8 (Name of Head of Facility), only ☐ Update/ Amendment
check the appropriate box if the HoF has no middle name or has a single name (mononym).
5. If Change in HoF is selected under Section No. 12.B (Update/ Amendment), kindly indicate HF PHILHEALTH ACCREDITATION
the contact information, designation, PAN and validity of PAN of the HoF (if applicable) in NUMBER (PAN):
the “TO” column.
6. All transactions under Section No. 12.B (Update/ Amendment) requires no accreditation fee. Not applicable for initial application.
address at _______________________________________________________________
PUROK 1, OLUTANGA, ZAMBOANGA SIBUGAY and the duly authorized representative to
Address of the Authorized Representative
act for and in behalf of the health facility, hereby submits the following pertinent information and documentary requirements under Section 56
of the Revised Implementing Rules and Regulations of the National Health Insurance Act of 2013 (R.A. No. 7875, as amended by R.A. No. 9241
and 10606).
NAME
1
ZAMBOANGA SIBUGAY
Province and/or Region
7
ZIP Code
0 4 1 7 2 . 1
Latitude (XX.XXXXX)
5 5 0 N 1 2 2 .
Longitude (XXX.XXXXX)
5 0 4 6 E
3HF CONTACT 09173014761 janiceque_28@yahoo.com
INFORMATION:
Landline and/or Mobile Number Official Email Address
9 HF CATEGORY
☐ Hospital ☐ Primary Care Facility ☐ COVID-19 Testing Laboratory
Level ☐3 ☐2 ☐1 ☐ Birthing Home
Authorized Bed Capacity (ABC): ______________ ☐ RT-PCR ☐ Cartridge-based
With Hospital Extension Facility (HEF)? ☐ Y ☐ N
☐ TB DOTS Clinic ☐ Drug Abuse Treatment &
HEF address (if Y): ☐ Animal Bite Treatment Clinic Rehabilitation Center
_____________________________________ ☐ Family Planning Clinic ☐ DepEd Clinic
_____________________________________ ☐ HIV-AIDS Treatment Hub ☐ Others
_____________________________________ ☐ Rural Health Unit/ Health ___________________________
_____________________________________ Center
_____________________________________
___________________________
☐ City/ Municipal Health Office __________________________
☐ Infirmary ☐ Provincial Health Office ___________________________
☐ Ambulatory Surgical Clinic ☐ Barangay Health Station ___________________________
☐ Dialysis Clinic ☐ Community Isolation Unit ___________________________
☐ Hemodialysis ☐ Peritoneal Dialysis
10 PHILHEALTH BENEFIT PACKAGE/S OFFERED:
11 NATURE OF OWNERSHIP:
☐ Government ☐ Private
☐ DOH-Retained ☐ State Universities and Colleges ☐ Single Proprietorship ☐ Others
☐ Provincial ☐ Government-owned and/or Controlled Corporation ☐ Partnership
☐ City/ Municipal ☐ Others ☐ Cooperative _____________________________
☐ Foundation
☐ DND ☐ DOJ __________________________________________ _____________________________
☐ Corporation
☐ PNP __________________________________________ _____________________________
Continue on separate Continue on separate
Name/s of the Local Chief Executive/s (if Government): sheet if necessary. Name/s of the Owner/s (if Private): sheet if necessary.
______________________________________________________________________ _________________________________________________________
______________________________________________________________________ _________________________________________________________
______________________________________________________________________ _________________________________________________________
______________________________________________________________________
ANN K. HOFER _________________________________________________________
______________________________________________________________________
Provincial Governor _________________________________________________________
______________________________________________________________________ _________________________________________________________
______________________________________________________________________ _________________________________________________________
______________________________________________________________________ _________________________________________________________
__________________________________________________ __________________________________________________
☐ Transfer of location __________________________________________________ __________________________________________________
☐ Upgrading of facility level or __________________________________________________ __________________________________________________
category
☐ Change in classification __________________________________________________ __________________________________________________
☐ Change in ownership __________________________________________________ __________________________________________________
__________________________________________________ __________________________________________________
☐ Previous accreditation has lapsed/ ☐ Failure to submit the requirements for continuous ☐ Resumption of operation after closure/
Subsequent application was denied accreditation within the prescribed period cessation of operation
Under penalty of law, I hereby attest that the information provided, including the documents I have attached to this form, are true
and accurate to the best of my knowledge. I agree and authorize PhilHealth for the subsequent validation, verification and for
other data sharing purposes only under the following circumstances:
As necessary for the proper execution of processes related to the legitimate and declared purpose;
The use or disclosure is reasonably necessary, required or authorized by or under the law, and;
Adequate security measures are employed to protect my information.