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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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 :

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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 :

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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 :

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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 :

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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 :
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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 :
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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 :
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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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