Follow the steps to fill out your form correctly:

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the name of the healthcare institution in the designated space. Ensure that you print legibly to avoid any misunderstandings.
3. Provide your accreditation number(s) and PhilHealth employer number accurately in the corresponding fields.
4. Fill in the mailing or billing address, ensuring to include the street number, barangay, municipality or city, province, and ZIP code as applicable.
5. Enter your contact information, including fax number, contact number, and a mandatory official email address.
6. Input the details of the facility head, medical director, or chief of the hospital including their contact information and email address.
7. Indicate the type of health care facility by checking the appropriate level under the hospital section or other health facilities, specifying necessary details like DOH-LTO number and validity where requested.
8. Indicate the nature of ownership of your health care institution, selecting from options such as government, private, or cooperative, and include the name of the owner(s) if applicable.
9. Select the type of application you are submitting by checking the appropriate box for initial application, re-accreditation, continuous accreditation, or any other specified changes.
10. Review all the entered information for accuracy before proceeding. After double-checking, you can save changes, download, print, or share the completed form as necessary.

Complete your PH Provider Data Record Health Care Institution online today to ensure your facility is registered and compliant.