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Review Checklist For Hospital Renewal

This document is a review checklist used by the Department of Health Regional Office IV-A for hospital license renewal applications. It lists documents that must be submitted and checked for completeness, including an application form, sworn statement, list of X-ray machines, subscription and dose reports, certificates of participation in laboratory testing programs, dialysis clinic documents if applicable, blood bank documents if applicable, annual statistics reports, and the current license. Space is provided to note any lacking documents.

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Rhodora Benipayo
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574 views1 page

Review Checklist For Hospital Renewal

This document is a review checklist used by the Department of Health Regional Office IV-A for hospital license renewal applications. It lists documents that must be submitted and checked for completeness, including an application form, sworn statement, list of X-ray machines, subscription and dose reports, certificates of participation in laboratory testing programs, dialysis clinic documents if applicable, blood bank documents if applicable, annual statistics reports, and the current license. Space is provided to note any lacking documents.

Uploaded by

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

Department of Health
REGIONAL OFFICE IV-A
Regulations, Licensing Enforcement Division
QMMC Compound, Project 4 Quezon City

Name of Facility: ____________________________________________________________


REVIEW CHECKLIST FOR HOSPITAL RENEWAL APPLICATION

Please check the availability of the following documents under YES NO


column Yes or No
Properly accomplished Application for LTO
Signed and notarized sworn statement
List of X-ray Machines (Annex G)
Photocopy of OSL Subscription for one year
Photocopy of Film Badge Dose Reports within the validity period of
hospital license
Certificate of Participation from NRL (if applicable)
Hematology (NKTI)
Chemistry (LCP)
Hepatitis B/HIV/AIDS (SACCL)
Microbiology (RITM)
Dialysis Clinic (When provided by the hospital)
Certificate of Compliance
Documented Quality Assurance Program
Blood Station/Blood Collecting Unit/Blood Bank (When provided by the hospital)
Annual Accomplishment Report using NVBSP
Form
Annual Hospital Statistics Report
Accomplished Health Facility Geographic Form
Latest copy of License to operate
Compliance to Deficiencies (last monitoring) if monitored
Remarks/List of Lacking Documents:

_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

Evaluated by: __________________________________________________________


(Name and Signature)

Date Evaluated: _______________________________________________________

DOH-C4A-RHF-HOSR-Rev.2

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