CHECKLIST OF REQUIREMENTS for IHCPs BASIC PARTICIPATION (Initial)

______ Performance Commitment ______ Providers Data Record ______ Participation fee ______ Latest audited financial statement/report ______ Electronic copies of recent photo of the facility ______ Statement of Intent (for last quarter application) O+tri64t For S+r()2

CHECKLIST OF REQUIREMENTS for IHCPs BASIC PARTICIPATION (Initial)

______ Performance Commitment ______ Providers Data Record ______ Participation fee ______ Latest audited financial statement/report ______ Electronic copies of recent photo of the facility ______ Statement of Intent (for last quarter application) O+tri64t For s+r()2

ADDITIONAL REQUIREMENT for BASIC PARTICIPATION HOSPITAL ASC FDC

_____ D ! License "ith validity applica#le to the en$a$ement period applied for% _____ D ! Licenses for & previous years or its re'uired alternative document (PC !"s !##$) for initial en$a$ement of licensed I!CPs

ADDITIONAL REQUIREMENT for BASIC PARTICIPATION HOSPITAL ASC FDC

_____ D ! License "ith validity applica#le to the en$a$ement period applied for% _____ D ! Licenses for & previous years or its re'uired alternative document (PC !"s !##$) for initial en$a$ement of licensed I!CPs

AD%ANCED PARTICIPATION
&&&&&&& Letter of Intent for (dvanced Participation _______ (ccomplished Self)(ssessment tool for (dvanced Participation (Certified #y I( ) "ith passin$ score% _______ *inancial Ris+ Protection ,odule _______ -uality !ealth Care ,odule _______ (dvanced Participation *ee

AD%ANCED PARTICIPATION
&&&&&&& Letter of Intent for (dvanced Participation _______ (ccomplished Self)(ssessment tool for (dvanced Participation (Certified #y I( ) "ith passin$ score% _______ *inancial Ris+ Protection ,odule _______ -uality !ealth Care ,odule _______ (dvanced Participation *ee

RE'ISTRATION FEE
INSTITUTION INITIAL (Pri(at) 'o()rn*)nt) Ann+al Parti,i-ation f))

RE'ISTRATION FEE
INSTITUTION INITIAL (Pri(at) 'o()rn*)nt) Ann+al Parti,i-ation f))

(SC ./000%00 (*DC) !D 2 PD ./000%00 PC3 4/000%00 53 D 5S 4/000%00 ,CP 4/.00%00 PC3/,CP/53 4/000%00 D 5S PC3 / 53 D 5S 4/000%00 PC3/ ,CP 4/.00%00 ,CP/ 53 D 5S 4/.00%00 (3P 4/000%00 LE6EL 4 !ospital / Infirmary(& years
moratorium)

1/000%00 ./000%00 4/000%00 4/000%00 4/000%00 4/000%00 4/000%00 4/.00%00 4/.00%00 4/000%00 &/000%00 ./000%00 7/000%00 40/000%00 40/000%00

(SC ./000%00 (*DC) !D 2 PD ./000%00 PC3 4/000%00 53 D 5S 4/000%00 ,CP 4/.00%00 PC3/,CP/53 4/000%00 D 5S PC3 / 53 D 5S 4/000%00 PC3/ ,CP 4/.00%00 ,CP/ 53 D 5S 4/.00%00 (3P 4/000%00 LE6EL 4 !ospital / Infirmary(& years
moratorium)

1/000%00 ./000%00 4/000%00 4/000%00 4/000%00 4/000%00 4/000%00 4/.00%00 4/.00%00 4/000%00 &/000%00 ./000%00 7/000%00 40/000%00 40/000%00

LE6EL II !ospital LE6EL II !ospital LE6EL III !ospitals (5eachin$ !ospital) LE6EL I6 !ospital ( under & years
moratorium)

LE6EL II !ospital LE6EL II !ospital LE6EL III !ospitals (5eachin$ !ospital) LE6EL I6 !ospital ( under & years moratorium)

CONTINUOUS PARTICIPATION &&&&& Providers Data Record

______ 8pdated D ! License ______ Performance Commitment ______ Updated Certificates issued by DOH/CHD or any 3 party Accrediting body duly recognized by Philhealth.( if applicable ______ Latest (udited *inancial Statement ______ Proof of payment of the participation fee%

CONTINUOUS PARTICIPATION &&&&& Providers Data Record

______ 8pdated D ! License ______ Performance Commitment ______ Updated Certificates issued by DOH/CHD or any 3 party Accrediting body duly recognized by Philhealth.( if applicable) ______ Latest (udited *inancial Statement ______ Proof of payment of the participation fee%

ADDITIONAL REQUIREMENT FOR CONTINUOUS PARTICIPATION

______ electronic copy photo of facility if "ith chan$es (include date ta+en) ______ Certificate as 9e"#orn Screenin$ *acility (for hospitals only) ______ (vaila#ility of Internet Connection/ I!CP Portal .ES NO
(If No/ as0 for ,)rtifi,ation of non a(aila1ilit2 of int)rn)t -ro(i3)r in t4) ar)a)

ADDITIONAL REQUIREMENT FOR CONTINUOUS PARTICIPATION

______ electronic copy photo of facility if "ith chan$es (include date ta+en) ______ Certificate as 9e"#orn Screenin$ *acility (for hospitals only) ______ (vaila#ility of Internet Connection/ I!CP Portal .ES NO (If No/ as0 for ,)rtifi,ation of non a(aila1ilit2 of int)rn)t -ro(i3)r in t4) ar)a) ______ 8pdated copy of R* 4 (as reference for list of personnel) ______ r$ani:ational Chart

______ 8pdated copy of R* 4 (as reference for list of personnel) ______ r$ani:ational Chart

PRIMAR. CARE BENEFIT " PRO%IDER

&&&&& MOA "ith referral facility ; if applica#le _____ Location map (to validate veracity) _____ Tr+st F+n3 ( certified #y the Local (ccountin$ <=s/<04& ) fficer as per PC

PRIMAR. CARE BENEFIT " PRO%IDER

&&&&& MOA "ith referral facility ; if applica#le _____ Location map (to validate veracity) _____ Tr+st F+n3 ( certified #y the Local (ccountin$ <=s/<04& ) fficer as per PC

OUTPATIENT MALARIA PACKA'E PRO%IDER

_____ Certificate of 5rainin$ in ,alaria of a staff in the I!CP issued #y D !/C!D%

OUTPATIENT MALARIA PACKA'E PRO%IDER

_____ Certificate of 5rainin$ in ,alaria of a staff in the I!CP issued #y D !/C!D%

MATERNIT. CARE PACKA'E PRO%IDER

_____ C)rtifi,at) of ,o*-lian,) as a BE*ONC facility (for automatic accreditation) _____ Certificate as N)51orn S,r))nin6 Fa,ilit2 issued #y C!D or 9SRC% (9e"#orn Screenin$ Reference Center)

MATERNIT. CARE PACKA'E PRO%IDER

_____ C)rtifi,at) of ,o*-lian,) as a BE*ONC facility (for automatic accreditation) _____ Certificate as N)51orn S,r))nin6 Fa,ilit2 issued #y C!D or 9SRC% (9e"#orn Screenin$ Reference Center) Any of the following for applicable referral system

CHECKLIST OF REQUIREMENTS PR 6IDER PR *ILE 8PD(5E (RE)(CCREDI5(5I 9)

As per Philhealth Circular 11,s. 2013

CHECKLIST OF REQUIREMENTS PR 6IDER PR *ILE 8PD(5E (RE)(CCREDI5(5I 9)

As per Philhealth Circular 11,s. 2013

"7 8it4 'AP 5it43ra5n fro* a,,r)3itation !7 Transf)r of lo,ation 97 A33itional s)r(i,) :7 R)s+*-tion of o-)ration ;7 U-6ra3in6 of L)()l <7 C4an6) in Classifi,ation (eg. !ro" #eneral to $pecialty hospital ) ______ Performance Commitment ______ Providers Data Record ______ Participation fee ______ Latest audited financial statement/report ______ Electronic copies of recent photo of the facility ______ Statement of Intent (for last quarter application) =7 In,r)as) in 1)3s ______ License only >7 C4an6) of o5n)rs4i- ( A$C/!DC/Hospitals ______ Letter re'uest ______ Proof of chan$e in o"nership (eg. !C, "ee# of ale, "$% Certificate) $7 C4an6) of o5n)rs4i- ( for pri%ate &CP' () DO($' A)PP &&&&&& ,ayors Permit RE'ISTRATION FEE
INSTITUTION INITIAL (Pri(at) 'o()rn*)nt) ./000%00 ./000%00 4/000%00 4/000%00 4/.00%00 4/000%00 Ann+al Parti,i-ation f)) 1/000%00 ./000%00 4/000%00 4/000%00 4/000%00 4/000%00 4/000%00 4/.00%00 4/.00%00 4/000%00 &/000%00 ./000%00 7/000%00 40/000%00

"7 8it4 'AP 5it43ra5n fro* a,,r)3itation !7 Transf)r of lo,ation 97 A33itional s)r(i,) :7 R)s+*-tion of o-)ration ;7 U-6ra3in6 of L)()l <7 C4an6) in Classifi,ation (eg. !ro" #eneral to $pecialty hospital ) ______ Performance Commitment ______ Providers Data Record ______ Participation fee ______ Latest audited financial statement/report ______ Electronic copies of recent photo of the facility ______ Statement of Intent (for last quarter application) =7 In,r)as) in 1)3s ______ License only >7 C4an6) of o5n)rs4i- ( A$C/!DC/Hospitals ______ Letter re'uest ______ Proof of chan$e in o"nership (eg. !C, "ee# of ale, "$% Certificate) $7 C4an6) of o5n)rs4i- ( for pri%ate &CP' () DO($' A)PP &&&&&& ,ayors Permit RE'ISTRATION FEE
INSTITUTION INITIAL (Pri(at) 'o()rn*)nt) ./000%00 ./000%00 4/000%00 4/000%00 4/.00%00 4/000%00 Ann+al Parti,i-ation f)) 1/000%00 ./000%00 4/000%00 4/000%00 4/000%00 4/000%00 4/000%00 4/.00%00 4/.00%00 4/000%00 &/000%00 ./000%00 7/000%00 40/000%00

(SC (*DC) !D 2 PD PC3 53 D 5S ,CP PC3/,CP/53 D 5S PC3 / 53 D 5S 4/000%00 PC3/ ,CP 4/.00%00 ,CP/ 53 D 5S 4/.00%00 (3P 4/000%00 LE6EL 4 !ospital / Infirmary(& years moratorium) LE6EL II !ospital LE6EL II !ospital LE6EL III !ospitals (5eachin$ !ospital)

(SC (*DC) !D 2 PD PC3 53 D 5S ,CP PC3/,CP/53 D 5S PC3 / 53 D 5S 4/000%00 PC3/ ,CP 4/.00%00 ,CP/ 53 D 5S 4/.00%00 (3P 4/000%00 LE6EL 4 !ospital / Infirmary(& years moratorium) LE6EL II !ospital LE6EL II !ospital LE6EL III !ospitals (5eachin$ !ospital)

CHECKLIST OF REQUIREMENTS PR 6IDER PR *ILE 8PD(5E (RE)(CCREDI5(5I 9)

As per Philhealth Circular 11,s. 2013

CHECKLIST OF REQUIREMENTS PR 6IDER PR *ILE 8PD(5E (RE)(CCREDI5(5I 9)

As per Philhealth Circular 11,s. 2013

"7 8it4 'AP 5it43ra5n fro* a,,r)3itation !7 Transf)r of lo,ation 97 A33itional s)r(i,) :7 R)s+*-tion of o-)ration ;7 U-6ra3in6 of L)()l <7 C4an6) in Classifi,ation (eg. !ro" #eneral to $pecialty hospital ) ______ Performance Commitment ______ Providers Data Record ______ Participation fee ______ Latest audited financial statement/report ______ Electronic copies of recent photo of the facility ______ Statement of Intent (for last quarter application) =7 In,r)as) in 1)3s ______ License only >7 C4an6) of o5n)rs4i- ( A$C/!DC/Hospitals ______ Letter re'uest ______ Proof of chan$e in o"nership (eg. !C, "ee# of ale, "$% Certificate) $7 C4an6) of o5n)rs4i- ( for pri%ate &CP' () DO($' A)PP &&&&&& ,ayors Permit RE'ISTRATION FEE
INSTITUTION INITIAL (Pri(at) 'o()rn*)nt) ./000%00 ./000%00 4/000%00 4/000%00 4/.00%00 4/000%00 Ann+al Parti,i-ation f)) 1/000%00 ./000%00 4/000%00 4/000%00 4/000%00 4/000%00 4/000%00 4/.00%00 4/.00%00 4/000%00 &/000%00 ./000%00 7/000%00 40/000%00

"7 8it4 'AP 5it43ra5n fro* a,,r)3itation !7 Transf)r of lo,ation 97 A33itional s)r(i,) :7 R)s+*-tion of o-)ration ;7 U-6ra3in6 of L)()l <7 C4an6) in Classifi,ation (eg. !ro" #eneral to $pecialty hospital ) ______ Performance Commitment ______ Providers Data Record ______ Participation fee ______ Latest audited financial statement/report ______ Electronic copies of recent photo of the facility ______ Statement of Intent (for last quarter application) =7 In,r)as) in 1)3s ______ License only >7 C4an6) of o5n)rs4i- ( A$C/!DC/Hospitals ______ Letter re'uest ______ Proof of chan$e in o"nership (eg. !C, "ee# of ale, "$% Certificate) $7 C4an6) of o5n)rs4i- ( for pri%ate &CP' () DO($' A)PP &&&&&& ,ayors Permit RE'ISTRATION FEE
INSTITUTION INITIAL (Pri(at) 'o()rn*)nt) ./000%00 ./000%00 4/000%00 4/000%00 4/.00%00 4/000%00 Ann+al Parti,i-ation f)) 1/000%00 ./000%00 4/000%00 4/000%00 4/000%00 4/000%00 4/000%00 4/.00%00 4/.00%00 4/000%00 &/000%00 ./000%00 7/000%00 40/000%00

(SC (*DC) !D 2 PD PC3 53 D 5S ,CP PC3/,CP/53 D 5S PC3 / 53 D 5S 4/000%00 PC3/ ,CP 4/.00%00 ,CP/ 53 D 5S 4/.00%00 (3P 4/000%00 LE6EL 4 !ospital / Infirmary(& years moratorium) LE6EL II !ospital LE6EL II !ospital LE6EL III !ospitals (5eachin$ !ospital)

(SC (*DC) !D 2 PD PC3 53 D 5S ,CP PC3/,CP/53 D 5S PC3 / 53 D 5S 4/000%00 PC3/ ,CP 4/.00%00 ,CP/ 53 D 5S 4/.00%00 (3P 4/000%00 LE6EL 4 !ospital / Infirmary(& years moratorium) LE6EL II !ospital LE6EL II !ospital LE6EL III !ospitals (5eachin$ !ospital)

CHECKLIST OF REQUIREMENTS (CCREDI5(5I 9 * !E(L5! C(RE PR *ESSSI 9(LS (s per PC ../ s% <04<

CHECKLIST OF REQUIREMENTS (CCREDI5(5I 9 * !E(L5! C(RE PR *ESSSI 9(LS (s per PC ../ s% <04<

I ? 'o()rn*)nt ? INITIAL #eneral Practitioner/ Dentist and &id*ife o ____ (pplication form o ____ duly notari:ed "arranties of accreditation o ____ < pcs 4>4 recent picture o ____ photocopy of PRC license or its e'uivalent o ____ photocopy of 5I9 card o ____ affidavit of s"orn declaration of current $ross income (with pri&ate practice ' for ta( up#ating) o ____ service record o ____ appointment paper #eneral Practitioner *ith (raining+ o same as a#ove plus?% o ____ Completed Residency 5rainin$ Certificate% &edical $pecialist+ o ____ Specialty 3oard Certificate II ? 'o()rn*)nt ? RENE8AL #eneral Practitioner/ &edical $pecialist / Dentist / &id*ife o ____ (pplication form
CHECKLIST OF REQUIREMENTS (CCREDI5(5I 9 * !E(L5! C(RE PR *ESSSI 9(LS (s per PC ../ s% <04<

I ? 'o()rn*)nt ? INITIAL #eneral Practitioner/ Dentist and &id*ife o ____ (pplication form o ____ duly notari:ed "arranties of accreditation o ____ < pcs 4>4 recent picture o ____ photocopy of PRC license or its e'uivalent o ____ photocopy of 5I9 card o ____ affidavit of s"orn declaration of current $ross income (with pri&ate practice ' for ta( up#ating) o ____ service record o ____ appointment paper #eneral Practitioner *ith (raining+ o same as a#ove plus?% o ____ Completed Residency 5rainin$ Certificate% &edical $pecialist+ o ____ Specialty 3oard Certificate II ? 'o()rn*)nt ? RENE8AL #eneral Practitioner/ &edical $pecialist / Dentist / &id*ife o ____ (pplication form
CHECKLIST OF REQUIREMENTS (CCREDI5(5I 9 * !E(L5! C(RE PR *ESSSI 9(LS (s per PC ../ s% <04<

I ? Pri(at) ? INITIAL #eneral Practitioner/ Dentist o ____ (pplication form o ____ duly notari:ed "arranties of accreditation o ____ < pcs 4>4 recent picture o ____ photocopy of PRC license or its e'uivalent o ____ photocopy of 5I9 card o ____ Certificate of Re$istration ( 3IR ) o ____ affidavit / s"orn declaration of current $ross income ( stampe# by the )%* ) o ____ appointment paper

I ? Pri(at) ? INITIAL #eneral Practitioner/ Dentist o ____ (pplication form o ____ duly notari:ed "arranties of accreditation o ____ < pcs 4>4 recent picture o ____ photocopy of PRC license or its e'uivalent o ____ photocopy of 5I9 card o ____Certificate of Re$istration ( 3IR ) o ____ affidavit / s"orn declaration of current $ross income ( stampe# by )%* ) o ____ appointment paper

____ Proof of premium contri#ution ( " 2)ar or 9

2)ars a3(an,) -a2*)nt for IPM@ from Philhealth@ R* 4 ) R@,4.@ Certification

____ Proof of premium contri#ution ( " 2)ar or 9

2)ars a3(an,) -a2*)nt for IPM@ from Philhealth@ R* 4 ) R@,4.@ Certification

#eneral Practitioner *ith (raining+ o same as a#ove plus?% o ____ Completed Residency 5rainin$ Certificate% &edical $pecialist+ o ____ Specialty 3oard Certificate

o #eneral Practitioner *ith (raining+ o same as a#ove plus?% o ____ Completed Residency 5rainin$ Certificate% &edical $pecialist+ o ____ Specialty 3oard Certificate

II ? Pri(at) ? RENE8AL II ? Pri(at) ? RENE8AL #eneral Practitioner/ &edical $pecialist / Dentist / #eneral Practitioner/ &edical $pecialist / Dentist / &id*ife &id*ife ____ (pplication form o ____ (pplication form CHECKLIST OF REQUIREMENTS o ____ duly notari:ed "arranties of accreditation o ____ duly notari:ed "arranties of accreditation (CCREDI5(5I 9 * !E(L5! C(RE PR *ESSSIo 9(LS o ____ < pcs 4>4 recent picture (s per PC ../ s% <04< o ____ < pcs 4>4 recent picture MID8IFE (PRI%ATE ) o , ( "ith any of the follo"in$ as referral for complicated 3 and Pediatric casesA ____ (ccredited partner physician I ?? INITIAL REAACCREDITATION o o o o o ____ (pplication form ____ duly notari:ed "arranties of accreditation ____ < pcs 4>4 recent picture ____ photocopy of PRC license ____ photocopy of 5I9 card ____ Proof of premium contri#ution (" 2)ar
or 9 2)ars a3(an,) -a2*)nt for IPM) ( 3/ Pedia) ____ Interlocal !ealth Done (IL!D) "hich allo"s sharin$ of human resources% ____ D ! certified 3Em 9C)CEm 9C net"or+ ____ (ccredited level 4 hospital

o o

II ?? RENE8AL o o o o o

(ny of the follo"in$ (not require# for gra#uates from 1++, onwar#)
Certificate of trainin$ from a pro$ram accredited #y CPE/ Council of the 3oard of ,id"ifery of the PRC orA 5rainin$ Certificate from D ! reco$ni:ed trainin$ pro$ram or Certificate of (pprenticeship for one or more years "ith P!IC (ccredited 3)

____ (pplication form ____ duly notari:ed "arranties of accreditation ____ < pcs 4>4 recent picture ____ photocopy of PRC license ____ photocopy of 5I9 card ____ Proof of premium contri#ution (" 2)ar
or 9 2)ars a3(an,) -a2*)nt for IPM)

o
o

, ( "ith any of the follo"in$ as referral for complicated 3 and Pediatric casesA

____ (ccredited partner physician

( 3/ Pedia)