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Cordillera Administrative Regional Office: Application Form Certificate of Need For New General Hospitals

This document is an application form for a Certificate of Need for new general hospitals in the Cordillera Administrative Regional Office of the Philippines Department of Health. The application requests information on the proposed hospital name, address, proponent details, classification by ownership and service capability, capital investment, site area, proposed bed capacity, and required documents. It also requests projections of the primary and secondary catchment populations to be served and details of any existing hospitals operated by the proponent. Upon submission of the completed application and required documents, the regional health office will review the application and may request additional requirements if there is more than one applicant for the same catchment area.

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317 views2 pages

Cordillera Administrative Regional Office: Application Form Certificate of Need For New General Hospitals

This document is an application form for a Certificate of Need for new general hospitals in the Cordillera Administrative Regional Office of the Philippines Department of Health. The application requests information on the proposed hospital name, address, proponent details, classification by ownership and service capability, capital investment, site area, proposed bed capacity, and required documents. It also requests projections of the primary and secondary catchment populations to be served and details of any existing hospitals operated by the proponent. Upon submission of the completed application and required documents, the regional health office will review the application and may request additional requirements if there is more than one applicant for the same catchment area.

Uploaded by

Rocky Montañer
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOC, PDF, TXT or read online on Scribd
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Republic of the Philippines

Department of Health
Cordillera Administrative Regional Office
APPLICATION FORM
CERTIFICATE OF NEED FOR NEW GENERAL HOSPITALS

Name of Proposed Hospital:

Complete Address of Proposed Hospital:

Name of

Proponent:

Address of

Proponent: Contact

Number:

Classification According to:


Ownership: Service Capability:
[ ] Government [ ] Level 1 [ ] Level 2 [ ] Level 3
[ ] Private
Total Capital Investment for the Proposed Hospital: P

Total Lot Area of the Proposed Site:

Proposed Total Bed Capacity:

CHECKLIST OF DOCUMENTS:
[ ] Application Form for Certificate of Need for Hospitals
[ ] Certification from Provincial Planning and Development Office that the Proposed
Hospital is part of the duly approved Provincial Hospital/Health Care Delivery Plan
(if available)
Note: The DOH-Regional Office may ask for additional requirements should there
be more than one applicant covering the same catchment area.
Documents Checked by:
Applic
Amount Paid ant
O.R. Number Signature above Printed
Date Name
Date

CON Application Form


Revision:01
12/03/2014
Page 1 of 2
Projected Primary and Secondary Catchment Population(P) of the Proposed Hospital
th
Barangay/Municipality/District/Province/Region Projected Population (5 year) of Catchment Area
Primary Catchment Area:

Secondary Catchment Area/s:

Total Projected Primary and Secondary Catchment Population (P) =

List of existing hospitals currently managed/operated by the Proponent, if any:


Name of Existing Location ABC* Category License Validity Date (Year/s) of Remarks
Hospital/s of Hospital Number Period Operation

*ABC – Authorized Bed Capacity


CON Application Form
Revision:01
12/03/2014
Page 2 of 2

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