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HFS Change Request Form

DOH request form for HFS change in dialysis clinic

Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: Republic of the Philippines
Department of Health

HEALTH FACILITIES AND SERVICES REGULATORY BUREAU
APPLICATION FOR PERMIT TO CONSTRUCT A HEALTH FACILITY
Name of Health Facility:
Address of Health Facility:
Number

Street

Barangay

City/ Municipality

Region

Name of Applicant:
Owner/ Head of Health Facility

Mailing Address:
Contact Number:
Classification According to:

Ownership:
Capability:

[
[
[
[
[
[

] Government

[

] Private

]
]
]
]
]

Ambulatory Surgical Clinic
Birthing Home
Dialysis Clinic
Drug Testing Laboratory
Drug Abuse Treatment and Rehabilitation Center
Residential
Non-Residential
[ ] Hospital
Function:
[
] General
[
] Specialty
(If General)
Level 1
Level 2

Level 3

[ ] Infirmary
[ ] Medical Facility for Overseas Workers and Seafarers
[ ] Psychiatric Care Facility
Acute-Chronic
Custodial
Proposed Bed Capacity (if applicable)
Type of Construction:
[

] New, specify

[

] Expansion/Renovation ( for existing health facility), specify

Attachment: (incomplete attachment shall be a ground for the denial of this application)
A. Letter of Intent for new and existing health facility (background and scope of the project);
B. For new health facility;
1. Certificate of Need from the DOH-Regional Office (for hospital below 100 Authorized Bed Capacity )

2. Proof of Registration of Name of Health Facility
2.1.

DTI/ SEC Registration including Articles of Incorporation and By-Laws (for private health facility)

2.2.

Enabling Act/ Board Resolution (for government health facility)

2.3

Cooperative Development Authority Registration including Articles of Cooperation and By-Laws

3. Three (3) Sets of Site Development Plans and Architectural Floor Plans (in blue print 20” x 30”)
3.1.

Signed and sealed by an Architect/Engineer

3.2.

Showing all areas with appropriate scale, dimension and labels

3.3.

Demonstrating proper spatial and functional relationships of areas (refer to Checklist for Review
of Floor Plan)
C. For expansion/renovation of existing health facility;
1. Latest DOH Approved Permit to Construct and Approved Floor Plan with latest copy of LTO/COA
2. Floor Plan indicating proposed change/s (refer to B.3)
D. Feasibility Study (for non-hospital based dialysis clinic only)
E.

Application Fee (refer to Schedule of Fees)

I hereby declare that this Application has been accomplished by me, and that the foregoing information and
attached documents required for the permit to construct are true and correct.

Signature Over Printed Name

Date:

Form-PTC-A
Revision: 04
10/17/2016
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