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

CHECKLIST OF REQUIREMENTS FOR HOSPITAL ACCREDITATION PHIC - PRIMARY DOH - LEVEL I

NAME OF HOSPITAL:_____________________________________________________ ADDRESS:______________________________________________________

________ 1. ________ 2. ________ 3. ________ 4. ________ 5. PhilHealth application form properly accomplished. Duly notarized Warranties of Accreditation. Current DOH License. Current PHA Certificate of Membership. List of functional / serviceable equipment signed by the Medical Director/ Administrator (Annex A). ________ 6. List of current hospital's room rates (Annex B). ________ 7. List of current hospital service charges (Annex C). ________ 8. Certificate of Affiliation or Memorandum of Agreement with a licensed clinical laboratory and radiology facility within the locality. a.) * Laboratory b.) * X-ray c.) * Pharmacy

* Optional.

If ancillary service/s is/are present, DOH license/s should be submitted.

________ 9. List of available emergency drugs. ________10. Complete list of hospital staff with respective designation and signature (Annex D). ________11. Accreditation fee by PMO payable to PHIC or cash paid directly to cashier and / or photocopy of OR from PRO. Accreditation fee is non-refundable. Renewal - P2,000.00 Initial - P3,000.00 Re-accreditation - P3,000.00 (see attached PhilHealth Circular No. 29, s.2004 and Payment Scheme) ________12. Quality Assurance Program. ________13. Photocopy of Remittance Form 1 (RF1) for the last quarter (for Private hospitals only). ________14. Updated Health Certificate of Kitchen personnel.

________15. Sanitary Permit for the current year. ________16. Fire Safety Inspection Certificate for the current year. ________17. International Classification of Diseases (ICD-10) Training Certificate. ________18. Financial Statement of the previous year.

Additional Requirements for Initial Accreditation:

________ 1. ________ 2. ________ 3. ________ 4. ________ 5. Current photograph of hospital facade and other available facilities. Organizational Chart. Current standard operating procedures. SEC License / DTI certificate / CDA certificate. DOH licenses of three (3) previous successive years.

DOCUMENTS SUBMITTED:
PRO / SO / Central Office: ________ Date Received: _________________ Received By: _________________ Date Re-filed: _________________

Assessed / Evaluated By:

Receiving Clerk ________ Date _________ AQAO / MO _________ Date _________ Returned By __________ Date _________

PRO / SO / Central Office staff are advised to strictly indicate the above data.

IMPORTANT: Applications not completely filled-in and/or lacking in requirements shall be returned.

Republic of the Philippine

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

PhilHealth ACCREDITATION FORM APPLICATION FOR ACCREDITATION ( PRIMARY ) DOH CATEGORY - LEVEL I
1 _____________________, 20___ THE PRESIDENT Philippine Health Insurance Corporation Pasig City, Philippines SIR : I, ______________________________, Filipino of legal age, ________________________ (Position / Designation) with address at __________________________________________ and the duly authorized representative to act for and in behalf of _______________________________________, ( Health Care Institution ) hereby applies for accreditation under 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. P

PART I - GENERAL INFORMATION

Name of Hospital : ________________________________ TIN: _____________________ Complete Address : ____________________________________ Postal Code : __________ E-Mail Address : ____________________________________________________________ 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___

PERSON PRIMARILY RESPONSIBLE FOR ALL PHILHEALTH ISSUES:

2 P NAME: ____________________________ DESIGNATION:_________________________

Ownership / Management
Private
( ( ( ( ( ) ) ) ) ) Single Proprietorship Partnership Cooperative Corporation Foundation

Government
( ) ( ) ( ) ( ) Local Government Unit National DND Others, specify _____________

For LGU hospital, please indicate the name of Mayor or Governor, office address, telephone nos. and e-mail address (if available). Name: _____________________________________________________________________________________ Office address: _______________________________________________________________ Telephone no.: ___________________ e-mail address: _______________________________

A.

PHYSICAL PLANT & ENVIRONMENT

1. Building ( ) Concrete ( ) Semi-concrete ( ) Wood ( ( ( ) ) ) Old structure Renovated New structure

2.

Sanitation and Safety Standard a. Water supply __________________________________ (Please attach the current Water Analysis Report) b. Electric Power __________________________________ Stand by generator ( ) Yes ( ) No c. Sewage Disposal Solid waste by ________________________________ Liquid waste by _________________________________ Pathological waste by _____________________________ Fire escape Fire extinguisher Toilet facilites ( ) ( ) ( ) Yes Yes Yes ( ) No ( ) No ( ) No

d. e. f. 3. 4.

Has there been any change in ownership or management ? ( ) Yes ( ) No If yes, when ? ________________________________ 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. C.

HOSPITAL BEDS

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

MANPOWER COMPLEMENT
1. Medical Service
a. Consultants: General Surgery OB-Gyn Pediatrics Internal Medicine Pathology Radiology Dental Others ____________________ b. Residents

( Indicate the Number )

Full Time ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________

Part Time ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________

Visiting ______ ______ ______ ______ ______ ______ ______ ______ ______

2. Nursing Service
a. Registered Nurse b. Registered Midwives c. Nursing Aides 3.

* Pharmacist (optional)

4. Laboratory & X-ray a. * Medical Technologist b. * Radio Technologist 5. Dentist 6. * Cook 7. Food Handlers 7. Administrative Service 8. Others

________ ________ ________ ________ ________ ________ ________

________ ________ ________ ________ ________ ________ ________

The personnel may be contracted out. A contract of service or memorandum of agreement with a service providers should be secured.

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

D.

CLINICAL FACILITIES
( ( ) ) Emergency room Doctor's / Consultation office

( ( ( ( ( ( ( ( ( ( ( (

) ) ) ) ) ) ) ) ) ) ) )

(optional) Laboratory Lic. No. _______________ valid from ___________ to ___________ Affiliation ( ) Yes ( ) No If yes, specify _______________________ * X-ray facility (optional) X-ray Lic. No. ___________________ valid from ___________ to ___________ Affiliation ( ) Yes ( ) No If yes, specify _______________________ Drug Room * Pharmacy (optional) Pharmacy Lic. No. _______________ valid from ___________ to ___________ Dental room Labor room Delivery room Recovery room Medical Records room * Kitchen ** Transport Vehicle or Ambulance Others, please specify _________________________________________

* Clinical laboratory

The services can be contracted out. A contract of service or memorandum of agreement with a service providers should be secured.

**

The Patient Transport Service may be contracted out, but the vehicle used for patient transport must be available for 24 hours. There must be a mechanism to ensure that it is readily available whenever there is a need to transfer patients to a higher level of facility or to transport patients to diagnostic facilities.

E.

EQUIPMENT

Submit complete list of existing functional or serviceable equipment under each facility. ( Please see Annex A )

F.

CLINICAL SERVICE
( ( ( ( ) ) ) ) General Medicine Obstetrics & Gynecology Pediatrics Others, specify _______________

G.

RECORDS
( ) Admission Logbook [ ] Prescribed logbook ( Follow PhilHealth Cir. No. 25 s. 2005 ) [ ] Computerized

Case No.

Date & Time of Admission

Name of Patient

Date of Birth

Sex

Address

Membership

Admitting Diagnosis

Attending Physician

Final Diagnosis

Disposition

Disposition Date & Time

(
Case No.

Emergency Room Logbook

Name of Patient Date of Birth Sex Address Membership Procedure Done (if applicable) Admitting Diagnosis Attending Physician

Date & Time of Admission

Diagnostic Radiology Logbook

Case No. Date of Examination Name of Patient Date of Birth Sex Type of Examination

Laboratory Logbook
Case No. Date of Examination Name of Patient Date of Birth Sex Type of Examination

( ( (

) ) )

Patient's chart Outpatient surgical logbook Mandatory monthly hospital reports

H.
1. 2. 3. 4. 5.

QUALITY ASSURANCE PROGRAM OF THE INSTITUTION

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

PART II WARRANTIES OF ACCREDITATION

The undersigned, as representative to act for and on behalf of

_________________________________________________________________________ ( Hospital ) located at ________________________________________________________________ ( complete address ) warrants the following :

1. ELIGIBILITY
1.1 That the aforenamed health care institution has been in operation for at least three years, 1.2 That it is duly licensed / accredited by the Department of Health, 1.3 That it shows a good track record in the provision of health care, 1.4 That it is a member of good standing of ____________________ duly recognized by (association) PhilHealth with its established standards and criteria, 1.5 That it has the human resources, equipment, physical structure and other requirements in conformity with standards established by the Corporation, 1.6 That it has an ongoing quality assurance program.

2. COMPLIANCE TO PERTINENT LAWS

2.1 That the aforenamed health care institution shall in the course of its participation with the NHI program by virtue of its accreditation comply with the provisions of the National Health Insurance Law (RA 7875), its Implementing Rules and Regulations, all administrative orders of the corporation, 2.2 That it shall comply at all times with the provisions of the Hospital Licensure Act (RA 4226), its prevailing Implementing Rules and Regulations (A.O # 147, s.2004), Administrative Order # 183, s.2004 for ambulatory surgical clinics as well as other Administrative Orders, 2.3 That all DOH-retained hospitals shall comply with the provisions of Administrative Order # 137, s.2002 on the waiver of excess fees and charges for PhilHealth indigent patients, 2.4 That it shall accept the formal program of Quality Assurance, payment mechanism and utilization review of the National Health Insurance Program, 2.5 That its personnel shall strictly adhere and comply at all times with the Codes of Ethics of the Medical and Nursing professions and other medical related professions of the Philippines, 2.6 That it shall strictly enforce a smoke-free policy within the premises of the health care institutions. Premises shall be understood to include all areas of a health care institution's compound regardless whether the same is inside or outside an enclosed structure.

2.7 That it shall strictly adhere and abide by the Expanded Senior Citizens Act of 2003 (R.A. 9257), A.O. # 177, s.2004 as implemented in PhilHealth Circular 2, s.2005.

3. CLINICAL SERVICES
3.1 That the aforenamed health care institution shall guarantee, safe adequate and standard medical care for all patients seeking medical care; and shall exercise observance of public health measures in case of communicable disease, 3.2 That it shall adopt referral protocols, strictly follow guidelines and health resource sharing arrangements of the Program, 3.3 That it shall extend without delay chargeable benefits due qualified members and beneficiaries, 3.4 That it shall not engage in unethical and illegal solicitation of patients for purposes of compensability under the NHI program, 3.5 That it shall maintain at all times the required personnel, serviceable equipment and facilities for use of patients.

4. CLINICAL RECORDS AND PREPARATION OF CLAIMS

4.1 That the aforenamed health care institution shall maintain and accomplish at all times accurate chronological records of all patients, services rendered and health outcomes resulting from such services and health expenditures on patient care, 4.2 That it shall keep a neat and systematic records file in a safe but accessible place for easy retrieval, 4.3 That it shall undertake measures to enter only true and correct data in all patients records and in the preparation of claims and ensure the filing of legitimate claims within the sixty (60) calendar days after the patients discharge, 4.4 That I, acting on behalf of this institution, together with the concerned personnel, shall take full responsibility for any omission or commission in the preparation of claims and in the entry of clinical records.

5. MANAGEMENT INFORMATION SYSTEM

5.1 That the aforenamed health care institution shall give proper information of its accreditation status by posting the PhilHealth certificate of accreditation in a very conspicuous place in the said institution, 5.2 That it shall post at its billing section updated information of the Programs benefits and procedural requirements and make available the necessary forms for patients use, 5.3 That it shall inform the Department of Health all reportable cases confined in the aforenamed institution, 5.4 That it shall immediately inform the PhilHealth in writing of any of the following changes in the institutions (1) location (2) ownership or management, or (3) closure or temporary cessation of hospital operation.

6. HOSPITAL INSPECTION / VISITATION / INVESTIGATION

6.1 That the aforenamed health care institution recognizes the authority of the PhilHealth and its duly authorized representative or agents deputized by PhilHealth to conduct inspection, visitation or investigation of the institution at anytime, 6.2 That the PhilHealth's duly authorized representative shall be accorded with courtesy and respect by the hospital management and staff during inspection / visitation / investigation of the institution, 6.3 That it shall cooperate in the inspection / visitation / investigation by making ready and available all hospital records (medical & financial) and other pertinent documents, 6.4 That it shall obey without delay summons, subpoena or subpoena duces tecum from the Corporation or Local Health Insurance Office. Finally, I hereby certify that I have read the provisions of these warranties and affirms that the PhilHealth, by virtue of its power under RA 7875 may suspend or revoke the accreditation of this institution if found to have violated any of the provisions of the National Health Insurance Act, or its Implementing Rules and Regulations and any of these Warranties of Accreditation.

____________________________________ MEDICAL DIRECTOR / ADMINISTRATOR (Signature over Printed Name)

SUBSCRIBED AND SWORN TO,

this

______

day

of

___________________,

20___ at ________________________________.

__________________________ Notary Public Until PTR No. Issued at Issued on _______________ ________________ ________________ ________________

Doc. No. _____________ Book No. _____________ Page No. _____________ Series of 20___

LEVEL 1 (PRIMARY)

ANNEX A

LIST OF FUNCTIONAL / SERVICEABLE EQUIPMENT / APPARATUSES / INSTRUMENTS

NAME OF HOSPITAL: ADDRESS: EQUIPMENT TYPE NUMBER REMARKS
( Functional, For repair, etc. )

FACILITY

I hereby declare under penalties of perjury that the answers given are true and correct to the best of my knowledge and belief.

Date Accomplished

Medical Director's / Administrator's Signature over printed name Res. Cert. No. Issued at: Issued on:

PRIMARY

Annex B

HOSPITAL'S ROOM RATES

NAME OF HOSPITAL : ADDRESS : CATEGORY : DOH BED CAPACITY : PHIC A C C R E D I T E D B E D : TYPE OF ROOMS WARD MALE FEMALE SEMI - PRIVATE PRIVATE SUITE DELIVERY ROOM OTHERS ROOM NO/S. NO. OF BEDS ACCREDITATION NO.: EFFECTIVITY OF ACCREDITATION:

ROOM RATES

AMENITIES

I hereby declare under penalties of perjury that the answers given are true and correct to the best of my knowledge and belief.

Date Accomplished

Medical Director's / Administrator's Signature over printed name Res. Cert. No.___________________________ Issued at ______________________________ Issued on ______________________________

LEVEL 1 (PRIMARY)

ANNEX C

LIST OF CURRENT HOSPITAL SERVICE CHARGES

SERVICES Laboratory procedure ( Optional) RATE

X-ray & other Radiologic procedures ( Optional )

Other ancillary procedures ( Optional )

I hereby declare under penalties of perjury that the answers given are true and correct to the best of my knowledge and belief.

Date Accomplished

Medical Director's / Administrator's Signature over printed name Res. Cert. No. Issued at Issued on

PRIMARY

ANNEX D

LIST OF HOSPITAL PERSONNEL

NAME
POSITION / SPECIALTY

EMPLOYMENT STATUS FULL TIME PART TIME VISITING ON CALL

PRC NO. FOR PROFESSIONALS

PHILHEALTH NO.

SIGNATURE

NOTE : In case of resignation of any of the above listed employees, submit appointment of replacement properly attested and subscribed to. I hereby declare under penalties of perjury that the answers given are true and correct to the best of my knowledge and belief.

Date Accomplished

Medical Director's / Administrator's Signature over printed name Res. Cert. No. Issued at Issued on