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Get PH Provider Data Record Health Care Institution 2014-2024

Pasig City Health Line 441-7444 www. philhealth. gov.ph PROVIDER DATA RECORD HEALTH CARE INSTITUTION THE PRESIDENT CEO Philippine Health Insurance Corporation Pasig City Philippines Sir/Madam I of legal age with Position/Designation address at in behalf of and the duly authorized representative to act for and hereby submits the following pertinent name of healthcare institution information and documentary requirements under Sec. 56 of the Implementing Rules and Regulations of RA 7875 as amended by RA 10606. PDR-March2014 Republic of the Philippines PHILIPPINE HEALTH INSURANCE CORPORATION City State Bldg. 709 Shaw Blvd. Name of Health Care Institution Please print legibly and provide appropriate spaces Accreditation Number/s PhilHealth Employer Number Mailing/Billing Address No*/St*/Brgy. Municipality /City Province ZIP Code Contact Information Fax No* Contact No* Official Email Address mandatory Facility Head/ Medical Director/Chief of Hospital/Hospital Administrator Contact Number Email Address A. Hospital General Level 1 Hospital Level Specialty DOH-LTO No Validity of DOH-LTO B. Other Health Facilities Primary Care Facilities Without Beds With Inpatient Beds Infirmary/Dispensary Medical Outpatient Package Providers Anti TB/DOTS Package Birthing Homes MCP DOTS and PCB MCP and DOTS PCB and DOTS Maternity Care Package MCP Primary Care Benefit PCB Outpatient Malaria Animal Bite Package Specialized Outpatient Facility Freestanding Dialysis Clinic FDC Ambulatory Surgical Clinic Nature of Ownership 1. Government 2. Private National - DOH retained Single Proprietor Name of incumbent LCE Type of Application Foundation Partnership Corporation Others Specify Local City District DND / DOJ State Unitversities / College Others Cooperative Civic organization Name of owner/s Please check Initial Application Re-accreditation transactions Continuous Accreditation Transfer of location Change in facility classification Upgrading of hospital level Additional service Resumption of operation after closure/ cease operation Change of ownership Application after incurring a gap in accreditation regardless of length of gap Previous Continuous Accreditation was withdrawn Profile Update Change in name change in contact Information For PhilHealth Use Only Remarks Date Received LHIO By PRO Date Evaluated LHIO/PRO Receiving Module PRO Data Entry Control No* Date Encoded OR No* Date Paid Amount. Name of Health Care Institution Please print legibly and provide appropriate spaces Accreditation Number/s PhilHealth Employer Number Mailing/Billing Address No*/St*/Brgy. Municipality /City Province ZIP Code Contact Information Fax No* Contact No* Official Email Address mandatory Facility Head/ Medical Director/Chief of Hospital/Hospital Administrator Contact Number Email Address A. Municipality /City Province ZIP Code Contact Information Fax No* Contact No* Official Email Address mandatory Facility Head/ Medical Director/Chief of Hospital/Hospital Administrator Contact Number Email Address A. Hospital General Level 1 Hospital Level Specialty DOH-LTO No Validity of DOH-LTO B. Other Health Facilities Primary Care Facilities Without Beds With Inpatient Beds Infirmary/Dispensary Medical Outpatient Package Providers Anti TB/DOTS Package Birthing Homes MCP DOTS and PCB MCP and DOTS PCB and DOTS Maternity Care Package MCP Primary Care Benefit PCB Outpatient Malaria Animal Bite Package Specialized Outpatient Facility Freestanding Dialysis Clinic FDC Ambulatory Surgical Clinic Nature of Ownership 1. .

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