BHFS Form No.
2-05 November 2004
APPLICATION FOR RENEWAL OF
LICENSE TO OPERATE
Date: ______________
The Director
Bureau of Health Facilities and Services
Department of Health
Manila
Sir/Madam:
I hereby apply for Renewal of License to Operate a hospital or other health facility pursuant to
Section 9 of R.A. 4226 Hospital Licensure Act.
In this regard, I am submitting the following information:
(Fill up all items by writing down the answer and/or putting a check on the appropriate boxes.)
Name of Hospital/Health Facility :
Complete Address Street :
Barangay
City/Municipality
Province
Region
Telephone and/or Fax Number :
Owner :
Chief of Hospital/Medical Director :
Chairman of the Board (If Corporation) :
Authorized Bed Capacity :
Classification : General [ ]
Special [ ]
Government [ ]
National [ ]
Local [ ]
Others
Private [ ]
Single Proprietorship [ ]
Partnership [ ]
Corporation [ ]
Civic Organization [ ]
Religious [ ]
Foundation [ ]
Others
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BHFS Form No. 2-05 November 2004
Primary Care Hospital [ ]
Secondary Care Hospital [ ]
Tertiary Care Hospital [ ]
Infirmary [ ]
Birthing Home [ ]
Acute Chronic Psychiatric Care Facility [ ]
Custodial Psychiatric Care Facility [ ]
Attached are the following documents:
(Submit complete documents.)
1. Letter of Application and Request for Inspection to the Director of the Center for Health
Development
2. List of Personnel
3. List of Equipment/Instrument
4. Fire Safety Inspection Certificate
5. Sanitary Permit
6. Health Certificate
7. Certificate of Operation (Autoclave, Dumbwaiter, Elevator, etc.)
8. Annual Hospital/Health Facility Statistical Report
Very truly yours,
_____________________________
Signature Above Printed Name
_____________________________
Position
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BHFS Form No. 2-05 November 2004
LIST OF PERSONNEL
Name of Hospital/Health Facility :
Fill up all items by writing down the answer and/or putting a check on the appropriate boxes.
STATUS
PRC
Temporary
Permanent
POSITION NAME TRAINING SIGNATURE
Casual
No.
Administrative Service
Use additional sheets when necessary
Prepared by :
application - renewal
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BHFS Form No. 2-05 November 2004
LIST OF PERSONNEL
Name of Hospital/Health Facility :
Fill up all items by writing down the answer and/or putting a check on the appropriate boxes.
STATUS
PRC
Temporary
Permanent
POSITION NAME TRAINING SIGNATURE
Casual
No.
Clinical Service
Use additional sheets when necessary
Prepared by :
application - renewal
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BHFS Form No. 2-05 November 2004
LIST OF PERSONNEL
Name of Hospital/Health Facility :
Fill up all items by writing down the answer and/or putting a check on the appropriate boxes.
STATUS
PRC
Temporary
Permanent
POSITION NAME TRAINING SIGNATURE
Casual
No.
Nursing Service
Use additional sheets when necessary.
Prepared by :
application - renewal
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BHFS Form No. 2-05 November 2004
LIST OF PERSONNEL
Name of Hospital/Health Facility :
Fill up all items by writing down the answer and/or putting a check on the appropriate boxes.
STATUS
PRC
Temporary
Permanent
POSITION NAME TRAINING SIGNATURE
Casual
No.
Ancillary Service
Use additional sheets when necessary.
Prepared by :
application - renewal
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BHFS Form No. 2-05 November 2004
LIST OF EQUIPMENT/INSTRUMENT
Name of Hospital/Health Facility :
Fill up all items by writing down the answer and/or putting a check on the appropriate boxes.
DATE CONDITION
ITEM ACQUIRED QTY Non- REMARKS
New Serviceable
Serviceable
Administrative Service
Use additional sheets when necessary.
Prepared by :
application - renewal
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BHFS Form No. 2-05 November 2004
LIST OF EQUIPMENT/INSTRUMENT
Name of Hospital/Health Facility :
Fill up all items by writing down the answer and/or putting a check on the appropriate boxes.
DATE CONDITION
ITEM ACQUIRED QTY Non- REMARKS
New Serviceable
Serviceable
Clinical Service
Use additional sheets when necessary.
Prepared by :
application - renewal
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BHFS Form No. 2-05 November 2004
LIST OF EQUIPMENT/INSTRUMENT
Name of Hospital/Health Facility :
Fill up all items by writing down the answer and/or putting a check on the appropriate boxes.
DATE CONDITION
ITEM ACQUIRED QTY Non- REMARKS
New Serviceable
Serviceable
Ancillary Service
Use additional sheets when necessary.
Prepared by :
application - renewal
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BHFS Form No. 2-05 November 2004
Republic of the Philippines )
City/Municipality of ________________ ) S. S.
I, ____________________________, ____________________________, of legal age,
Name Designation
______________, a resident of __________________________________________________________,
Civil Status Home Address
after having been sworn in accordance with law hereby depose and say that I am executing this affidavit
to attest to the truth of the foregoing statements and the attached documents required for the renewal of
license to operate a hospital or other health facility pursuant to Section 9 of R.A. 4226 Hospital
Licensure Act.
_____________________________
Signature
Subscribed and sworn to before me this _______ day of ______________, 20_______ at
_____________________ by the above affiant with Community Tax Certificate No.
_____________________ issued on _____________________ at _____________________.
NOTARY PUBLIC
My Commission Expires
December 31, 20______
Doc. No. ___________ ;
Page No. __________ ;
Book No. __________ ;
Series of 20 _________
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