Republic of the Philippines PHILIPPINE HEALTH INSURANCE CORPORATION

City State BLdg., 709 Shaw Blvd., Pasig City Health line 637-9999 loc. 1216, 1217, 1223 & 637-6265; www.philhealth.gov.ph

PHIC Accre-AF-2 08/09/10

APPLICATION FORM FOR ACCREDITATION INSTITUTIONAL HEALTH CARE PROVIDER

THE PRESIDENT & CEO Philippine Health Insurance Corporation Pasig City, Philippines Sir/Madam: I, _______________________________________________, of legal age, __________________________________ with
(Position/Designation)

address at ______________________________________________ and the duly authorized representative to act for and in behalf of _____________________________________, hereby applies for accreditation under Sec. 52 L of R.A. 7875
(name of Health Care Institution)

as amended by RA 9241 and its Implementing Rules and Regulations thereto. For this purpose, I hereby submit the following pertinent information and documentary requirements.

Type of Institution: (Please check) Hospital:

Award Applied For: Center of Safety Center of Quality C t of Excellence Center f E ll Hospital Level: Level 1 Level 2 L Level 3 l Level 4

Out Patient Clinic:

Ambulatory Surgical Clinic (ASC)
Free Standing Dialysis Clinic (FSDC)

Out Patient Benefit (OPB) Provider Malaria Package Provider Maternity Care Package Provider Anti TB/DOTS Package Provider

3-in-1 Accreditation 2-in-1 Accreditation OPB and MCP OPB and DOTS d MCP and DOTS

Type of Application: (Please check)

Initial Renewal
Late Filer

Re-accreditation
with gap in accreditation Upgrading/add'l services

Change in location/ownership Accreditation No.

Name of Institution:

( Please print legibly and provide appropriate spaces)

Mailing/Billing Address:
No. / St. / Brgy.

Municipality / City

Province

Zip Code

Other Contact Information

Contact No. Fax No. Email Address:

Medical Director/Chief of Hospital/Hospital Administrator/Head of Facility

Accreditation No.

Owner of the Institution

For PhilHealth Use Only

Date Evaluated: SO
PhRO

By: y By: By:

SO PhRO SO PhRO SO PhRO

_______________________ Control No. OR No. ________________ Date Paid: _____________ Amt Paid: _____________

Date Received: Date Encoded:

SO PhRO SO/PhRO (Receiving Module) PhRO (Data Entry)

Accreditation Department /101509

WARRANTIESOFACCREDITATIONFORINSTITUTIONALHEALTHCAREPROVIDERS
A.REPRESENTATIONOFELIGIBILITIES 1.Wearea(indicatetypeofinsitution)____________dulyregisteredandlicensedbytheDepartment ofHealth(DOH);(applicabletolicensedinstitutionsonly,namely:hospitals,ASCsandFSDCs) 2.Allourofficers,employees,otherpersonneland staffaremembersingoodstandingofthe NHIPandweundertaketomaintainactivemembershipintheNHIPbyregularlyremittingthe corresponding PHIC premium contributions of all our employees not only during the entire validityofouraccreditationasanInstitutionalHealthCareProvider(IHCP)butalsoduringthe corporateexistenceofourhealthcareinstitution; 3. We have read, understood and are fully aware of the provisions of R.A. 7875 including its ImplementingRules&Regulationsparticularlythatpertainingtoandgoverningtheextentand limits of the grant of our privilege to be an accredited IHCP of the NHIP administered by the PHIC. B. COMPLIANCE TO PERTINENT LAWS/RULES & REGULATIONS/POLICIES/ADMINISTRATIVE ORDERSANDISSUANCES 4.Weshallconductourhealthcareserviceoperationsstrictlyandfaithfullyinaccordancewith theprovisionsoftheRepublicAct7875asamendedastheNationalHealthInsuranceLawofthe PhilippinesincludingallitsImplementingRules&Regulations(IRR); 5. We shall strictly abide with all the implementing rules and regulations, memorandum circulars, office orders, special orders and other administrative issuances issued by the PHIC governingouraccreditation; 6.WeshallstrictlyabidewithallAdministrativeOrders,Circularsandsuchotherpolicies,rules andregulationsissuedbytheDepartmentofHealth(DOH)andallothergovernmentagencies andinstrumentalitiesgoverningtheoperationsofIHCPsandaffectingouraccreditationwiththe PHIC; 7. We shall strictly adhere and abide with all the pertinent statutory laws affecting the operationsofIHCPsandaffectingouraccreditationincluding,butnotlimitedto,theExpanded Senior Citizens Act of 2003 (R.A. 9257), the Breastfeeding Act (R.A. 7600), the Newborn Screening Act (R.A. 9288), the Cheaper Medicines Act (R.A. 9502), the Pharmacy Law (R.A. 5921),theMagnaCartaforDisabledPersons(RA9442)andallotherlawsthatmaythereafter be passed by the Congress of the Philippines or any other authorized instrumentalities of the government. C.CONDUCTOFCLINICALSERVICES,RECORDS,PREPARATIONOFCLAIMSANDUNDERTAKINGS OFPARTICIPATIONINTHENHIP 8. We are fully aware and we hereby acknowledge that accreditation with the NHIP administeredbythePHICisnotarightbutamereprivilegeasprovidedunderSection31,Article VIIofR.A.7875ontheAuthoritytoGrantAccreditationbythePHIC; 9.Wearefullyawareandweherebyacknowledgethatouraccreditationbeingamereprivilege extendedby the NHIP,thegrantofwhichmaybe provisional,temporaryandlimitedwithina particularperiodasmaybedeterminedbythePHIC.Wefurtheracknowledgeandacceptthat ouraccreditationincludingtheappurtenantbenefitsandopportunitiesincidentthereto,beinga mereprivilegemaybesuspended,shortened,preterminatedand/orrevokedatanytimeduring thetermofouraccreditationasmaybedeterminedbythePHICtoprotecttheinterestsofthe NHIP; 10.Wearefullyawareandweunconditionallyacknowledgeandagreethatanyviolationofany provision of our warranties of accreditation whether directly or indirectly, shall constitute breach of warranties and shall be a ground at the sole discretion of the PHIC, to suspend,

shorten,preterminateand/orrevokeouraccreditationincludingtheappurtenantbenefitsand opportunities incident thereto at any time during the term of our accreditation as may be determinedbythePHICtoprotecttheinterestsoftheNHIP; 11. We are fully aware and we unconditionally acknowledge and agree that any indication(s), adversereports/findingsofpatternoranyothersimilarincidentswhichmaybeindicativeofany illegal,irregularorimproperand/orunethicalconductofouroperationsmaybeagroundatthe discretion of the PHIC, to suspend, shorten, preterminate and/or revoke my accreditation including the appurtenant benefits and opportunities incident thereto at any time during the term of our accreditation as may be determined by the PHIC to protect the interests of the NHIP; 12.WeundertakethatallqualifiedNHIPbeneficiariesshallbegivenhighqualityofhealthcare serviceduethemwithoutdelayandthatweshalldeductwithoutdelaythecorrectamountof chargeablebenefitsduetoqualifiedmembersandbeneficiariesupondischarge; 13. We shall promote and protect the NHI Program against abuse, violation and/or over utilization of its Funds and we will not allow our institution to be a party to any act, scheme, planorcontractthatmaydirectlyorindirectlybeprejudicialtotheProgram; 14.Weshallnotdirectlyorindirectlyengageinanyformofunethicalorimproperpracticesas an accredited provider such as, but not limited to, solicitation of patients for purposes of compensability under the NHIP, the purpose and/or the end consideration of which tends unnecessary financial gain rather than promotion of the NHIP thereby ultimately undermining thegreaterinterestsandnoblepurposeoftheNHIP; 15.WeherebyundertakethatweshallimmediatelyreporttothePHIC,itsOfficersand/orto any of its personnel, any act(s) of illegal, improper and/or unethical practices of IHCP of the NHIPthatmayhavecometoourknowledgedirectlyorindirectly; 16. We shall undertake measures to ensure that we only enter true and correct data in all patientsrecords,shalltakefullresponsibilityforanyinaccuraciesand/orfalsitiesenteredinto and/or reflected in our patients records as well as in any omission, addition, inaccuracies and/orfalsitiesenteredintoand/orreflectedinclaimssubmittedtoPHICbyourinstitution,and we further undertake to file before the PHIC only legitimate claims recognizing the period of filingwithinthesixty(60)calendardaysafterthepatientsdischarge; 17.WeshallmakeavailableimmediatelyandpromptlyuponrequestforPHICpurposes,make availableacompletelistingofourscheduleofstandardproviderfeesreadilyavailabletoPHIC Officersandauthorizedpersonnel,members,dependentsand/orrepresentatives; D.MANAGEMENTINFORMATIONSYSTEM 18. We shall have a PhilHealth Bulletin Board for the posting of updated information of the NHIP(circulars,memoranda,IECmaterials,pricereferenceindex,etc.)locatedattheBillingSectionorina conspicuous place accessible to patients, members and dependents of the NHIP within our healthcarefacility; 19.Weshall,atalltimesmakeavailablethenecessaryformsforpatientsuse; 20.Weshall,atalltimesmakeavailableacopyofthePNDFforuseofhealthcareprofessionals; 21. In the event of suspension or revocation of our accreditation, we shall voluntarily cover/remove our "PhilHealthAccredited" Signage posted within our health care facility to accordinglyinformthemembersanddependentsoftheNHIP.Wefurtherundertakeandagree that in the event of our failure and/or refusal to accordingly cover/remove the "PhilHealth Accredited" Signage posted within our health care facility, the PHIC shall have the right to cover/remove the same the costs of which shall be directly chargeable to our institution. We finally undertake and agree that any misrepresentation and/or resulting damage and/or liabilities arising out or a consequence of our failure to cover/remove the "PhilHealth Accredited"Signageshallbetheexclusiveresponsibilityofourinstitution;

22.WeshallaccordinglyseekpriorconsentofthePHICwhentheofficialPhilHealthLogowillbe included in any information campaign material(s) or the like outside the regular information driveactivitiesconductedbythePHIC. E.ADMINISTRATIVEINVESTIGATIONS/REGULARSURVEYS/DOMICILIARYVISITATIONSONTHE CONDUCTOFOPERATIONSINTHEEXERCISEOFTHEPRIVILEGEOFACCREDITATION 23.WeunconditionallyrecognizetheauthorityofthePHIC,itsOfficersandpersonneland/orits duly authorized representatives to conduct regular surveys, domiciliary visits and/or conduct administrativeassessment(s)atanytimerelativetotheexerciseofourprivilegeandconductof ouroperationsasanaccreditedIHCPoftheNHIP; 24.WeundertakethatweshallfullycooperatewithdulyrecognizedauthoritiesofthePHICand anyotherauthorizedpersonnelandinstrumentalitiestoprovideaccesstopatientrecordsand submittoanyassessmenttobeconductedbythePHICrelativetoanyfindings,adversereports, pattern of utilization and/or any other acts indicative of any illegal, irregular and/or unethical practicesinouroperationsasanaccreditedIHCPoftheNHIPthatmaybeprejudicialortendsto underminethenoblepurposeoftheNHIPandmakeavailableallpertinentofficialrecordsand otherpertinentdocumentsincludingtheprovisionofcopiesthereof; 25. We undertake that we shall accordingly instruct our officers, employees and personnel to extendfullcooperationaswellextendduecourtesyandrespecttoallPHICofficers,employees and staff during the conduct of assessment/visitation/investigation of our operations as an accreditedIHCPoftheNHIP; 26.WeundertakethatweshallcomplywithoutdelayanyandallPHICssummons,subpoena, subpoenaducestecumandotherlegalorqualityassuranceprocesses; 27.Weundertakethatatanytimeduringtheperiodofouraccreditation,uponrequestofthe PHIC, we shall voluntarily and unconditionally sign and execute a new warranties of accreditationtocovertheremainingportionofouraccreditationortorenewouraccreditation asthecasemaybe,asasignofourgoodfaithandcontinuousdedicationandcommitmentto comply with the warranties of our accreditation, to support and promote the NHIP being administeredbythePHIC; 28. Finally, we hereby declare under penalties of perjury that the abovestated statements aretrueandcorrectwithoutanyconditionsandfreefrommisrepresentations. IN WITNESS HEREOF, I have hereunto set my hand this ____________ day of __________________,2_____at___________________,Philippines. _________________________________ Administrator/MedicalDirector/HeadofFacility
REPUBLICOFTHEPHILIPPINES CITYOF_________________)s.s.

SUBSCRIBEDANDSWORNtobeforemethis________dayof_________________,2______, Affiant exhibiting to me his/her Community Tax Certificate No._____________issued at_____________on______________________.

NOTARYPUBLIC Doc.No._________ PageNo.________ BookNo.________ SeriesNo.________

CHECKLIST OF REQUIREMENTS FOR APPLICATION FOR ACCREDITATION INSTITUTIONAL HEALTH CARE PROVIDERS (IHCPs)

I. General Requirements: _____ 1. PhilHealth application form - properly accomplished _____ 2. Warranties of Accreditation duly notarized _____ 3. Accreditation fee - proof of payment (see back for appropriate fee schedule).

II. Specific Requirements: (in addition to the above, the following are specific requirements per type of institution) A. Hospitals (Levels 1, 2, 3 and 4) _____ 1. DOH License with validity applicable to the accreditation period applied for _____ 2. Certificate of Membership in PHA or PHAP with validity applicable to the accreditation period applied for _____ 3. Benchbook Score Sheet _____ 4. Self-Assessment Summary _____ 5. Statement of Intent (SOI) if applicable a. For Hospitals applying for initial/re-accreditation from January to April regarding to validity of accreditation, and/or b. For hospitals applying as Centers of Quality/Excellence Additional Requirement for Initial Accreditation: _____ DOH licenses for 3 previous years or its required * alternative document

B. Ambulatory Surgical Clinics & Free Standing Dialysis Clinics _____ 1. Current DOH license _____ 2. Statement of Intent (SOI) if applicable * For FSDCs and ASCs applying for initial/re-accreditation from January to April regarding to validity of accreditation Additional Requirements for Initial Accreditation: _____ DOH license for 3 previous years or its required * alternative document C. Out Patient Benefit Package, Maternity Care Package, and Anti-TB/DOTS Package Providers: _____ 1. Location map _____ 2. PhilCAT Certificate optional for initial accreditation of DOTS Providers _____ 3. Proof of Affiliation with at least a Level 2 PhilHealth Accredited Hospital if applicable for an MCP Clinic _____ 4. Statement of Intent (SOI) if applicable * For providers applying for initial/re-accreditation from September to December regarding to validity of accreditation * NOTE: Applications for initial accreditation that are non-compliant with the three (3) year rule requirement may refer to PhilHealth Circ. 21 s. 2009 for alternative requirements.

III. Schedule of Accreditation Fees:

RENEWAL INITIAL & REACCREDITATION

RENEWAL (LATE FILERS)

INSTITUTIONS

(PRIVATE/ GOVERNMENT)

Level I Hospitals Level II Hospitals Level III Hospitals Level IV Hospitals (with training programs ) Ambulatory Surgical Centers (ASCs) Free Standing Dialysis Centers (FSDCs) OPB Providers TB-DOTS Provider Non-Hospital Maternity Care Providers 3-in-1 Providers OPB and DOTS Providers OPB and MCP Providers MCP and DOTS Providers

P 3,000.00 P 5,000.00 P 8,000.00 P 10,000.00 P 5,000.00 P 5,000.00 P 1,000.00 * P 1,000.00 P 1,500.00 P 1,000.00 * P 1,000.00 * P 1,500.00 * P 1,500.00

BEFORE THE APPLICATIONS FILED AFTER THE PRESCRIBED PRESCRIBED FILING PERIOD PRESCRIBED FILING (additional fee) FILING PERIOD PERIOD 31 90 days prior 1 30 days prior (WITH 10% to expiration to expiration INCENTIVES) P 1,800.00 P 2,000.00 P 4,000.00 P 8,000.00 P 3,600.00 P 4,000.00 P 8,000.00 P 16,000.00 P 7,200.00 P 8,000.00 P 16,000.00 P 32,000.00 P 9,000.00 P 3,600.00 P 4,500.00 P P P 900.00 900.00 900.00 P 10,000.00 P 4,000.00 P 5,000.00 P 1,000.00 P 1,000.00 P 1,000.00 P P P P 1,000.00 1,000.00 1,500.00 1,500.00 P 20,000.00 P 8,000.00 P 10,000.00 P 2,000.00 P 2,000.00 P 2,000.00 P P P P 2,000.00 2,000.00 3,000.00 3,000.00 P40,000.00 P 16,000.00 P 20,000.00 P 4,000.00 P 4,000.00 P 4,000.00 P P P P 4,000.00 4,000.00 6,000.00 6,000.00

P 900.00 P 900.00 P 1,350.00 P 1,350.00

* Applicable to government facilities only