Republic of the Philippines

Department of Health
HEALTH FACILITIES AND SERVICES REGULATORY BUREAU

APPLICATION F O R L I CENSE TO OPERATE AN AMBULATORY SURGICAL CLINIC

1
Name of Clinic :
Address of Clinic :
No. & Street Barangay

City/ Municipality Province Region

Telephone/ Fax No. :

Name of Owner :
Contact No. :

Classification According to
Ownership: [ ] Government [ ] Private

Service/s: [ ] Colorectal Surgery [ ] Pediatric Surgery

[ ] General Surgery [ ] Plastic/ Reconstructive Surgery
[ ] Oral Maxillo-Facial Surgery [ ] Reproductive Health Surgery
[ ] Ophthalmologic Surgery [ ] Thoracic Surgery
[ ] Orthopedic Surgery [ ] Urologic Surgery
[ ] Otorhinolaryngologic Surgery

Status of Application : [ ] Initial [ ] Renewal

License No.
Date Issued
Expiry Date

Checklist of Application Documents

Please tick (") the appropriate boxes under column B or C. Items shaded are not required.

A B C
Documents For Initial For Renewal
1. Notarized Application for License to Operate an Ambulatory Surgical Clinic (this
form)
2. Letter of Endorsement to the BHFS Director (if filed at DOH-Regional Office)
3. List of Surgical Operations/ Procedures
4. ICD-10 Certificate
5. Documented Quality Assurance Program
6. Photocopies of DOH License to Operate/ Certificate of Accreditation of ancillary
services being provided such as laboratory, pharmacy and x-ray
7. List of Personnel (use attached form)
8. Photocopies of the following:
8.1. Proof of qualification of the medical and paramedical staff
• PRC ID/ PRC Board Certificate
• Specialty Board Certificate of the medical staff
• Certificate of Training/ Record of Work Experience
8.2. Proof of employment of the medical, paramedical and administrative staff

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The name of ambulatory surgical clinic should match the DTI/ SEC Registration and Mayor’s/ Business Permit.
Form-ASC-LTO-A
Revision:02
12/03/2014
Page 1 of 4
 A B C
Documents For Initial For Renewal
9. List of Equipment/ Instrument (use attached form)
10. Health Facility Geographic Form (Location Map)
11. Photographs of the exterior and interior of the ambulatory surgical clinic
12. Photocopy of DOH Permit to Construct
13. DTI/ SEC Registration (for private clinic) OR
Issuance or Board Resolution (for government clinic)
14. Contract of Lease (if clinic is rented)
15. Memorandum of Agreement with the nearest Level 2 or Level 3 Hospital
16. Evidence-based clinical practice guidelines

Acknowledgement

REPUBLIC OF THE PHILIPPINES )

CITY/ MUNICIPALITY OF ) S.S.

I, , , of legal age, , a resident of

Name Civil Status Age
, after having been sworn in accordance with law hereby depose and
Address
say that I am executing this affidavit to attest to the completeness and truth of the foregoing information and the attached

documents required for the Registration and Licensure of Ambulatory Surgical Clinics in the Philippines pursuant to

Administrative Order No. 183 s. 2004 “Rules and Regulations Governing the Licensure and Registration of Ambulatory

Surgical Clinics”.

Signature

Before me, this day of 20 in the City/ Municipality of ,

Philippines, personally appeared

Owner Community Tax Number Issued at/ on

known to me to be the same person/s who executed the foregoing instrument and they acknowledge to me that the same is

their free act and deed.

IN WITNESS WHEREOF, I have hereunto set my hands this day of 20

Doc.No. NOTARY PUBLIC

PageNo. My Commission Expires
BookNo. Dec. 31. 200
Series of

Form-ASC-LTO-A
Revision:02
12/03/2014
Page 2 of 4
 List of Personnel

Annex A
Name of Ambulatory Surgical Clinic __________________________________________________________________________________
Address of Ambulatory Surgical Clinic ________________________________________________________________________________

Valid
Name Designation/ Highest Educational Attainment PRC Reg. No. Signature
Position From To

Annex A – List of Personnel

Page 3 of 4
 List of Equipment2

Annex B
Name of Ambulatory Surgical Clinic _________________________________________________________________________________
Address of Ambulatory Surgical Clinic _______________________________________________________________________________

Brand Name & Model Serial No. Quantity Date of Purchase

Annex B- List of Equipment

Page 4 of 4
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Equipment should be present, functional, and owned by the ambulatory surgical clinic applying for license to operate.