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CHECKLIST OF REQUIREMENTS for IHCPs
ASIC 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)
DDITIONAL REQUIREMENT for BASIC PARTICIPATIONOSPITAL ASC FDC
___ D! License "ith validity applica#le to the en$a$ement
periodplied for%___ D! Licenses for & previous years or its
re'uired alternative
document (PC !"s !##$) for initial en$a$ement of licensed
I!CPs
D%ANCED PARTICIPATION&&&&& Letter of Intent
for dvanced Participation_____ ccomplished Selfssessment tool for
dvanced Participationertified #y
I)"ith passin$ score%_______ *inancial Ris+ Protection
,odule_______ -uality !ealth Care ,odule
_____ dvanced Participation *ee
E'ISTRATION FEEINSTITUTION INITIAL
(Priat 'orn*nt)
Ann+al
Parti,i-ationf
SC .000%00 1000%00
(*DC) !D 2 PD .000%00 .000%00
PC3 4000%00 4000%00
53 D5S 4000%00 4000%00
,CP 4.00%00 4000%00
PC3/,CP/53D5S
4000%00 4000%00
PC3 / 53 D5S 4000%00 4000%00
PC3/ ,CP 4.00%00 4.00%00
,CP/ 53 D5S 4.00%00 4.00%00
3P 4000%00 4000%00
LE6EL 4 !ospital / Infirmary(& yearsmoratorium)
&000%00
LE6EL II !ospital .000%00
LE6EL II !ospital 7000%00
LE6EL III !ospitals (5eachin$ !ospital) 40000%00
LE6EL I6 !ospital ( under & yearsmoratorium)
40000%00
ONTINUOUS 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%
DDITIONAL REQUIREMENT FOR CONTINUOUSARTICIPATION____ 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
O(If No/ as0 for ,rtifi,ation of non aaila1ilit2 of intrnt
-roi3r in t4 ara)
____ 8pdated copy of R* 4 (as reference for list of
personnel)____ r$ani:ational Chart
RIMAR. CARE BENEFIT " PRO%IDER&&& MOA"ith referral
facility ; if applica#le___ Location map (to validate veracity)___
Tr+st F+n3( certified #y the Local ccountin$ fficer as per PCs
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CHECKLIST OF REQUIREMENTSPR6IDER PR*ILE 8PD5E (RECCREDI55I9)
As per Philhealth Circular 11,s. 2013
"7 8it4 'AP 5it43ra5n fro* a,,r3itation!7 Transfr of lo,ation97
A33itional sri,:7 Rs+*-tion of o-ration;7 U-6ra3in6 of Ll7 C4an6 of
o5nrs4i- ( A$C/!DC/Hospitals______ Letter re'uest______ Proof of
chan$e in o"nership (eg. !C, "ee# of ale, "$% Certificate)
$7 C4an6 of o5nrs4i- ( for pri%ate &CP' ) DO$'
A)PP&&&&&& ,ayors Permit
RE'ISTRATION FEEINSTITUTION INITIAL
(Priat 'orn*nt)
Ann+alParti,i-ation
f
SC .000%00 1000%00(*DC) !D 2 PD .000%00 .000%00
PC3 4000%00 4000%00
53 D5S 4000%00 4000%00
,CP 4.00%00 4000%00
PC3/,CP/53D5S
4000%00 4000%00
PC3 / 53 D5S 4000%00 4000%00
PC3/ ,CP 4.00%00 4.00%00
,CP/ 53 D5S 4.00%00 4.00%00
3P 4000%00 4000%00
LE6EL 4 !ospital / Infirmary(& yearsmoratorium)
&000%00
LE6EL II !ospital .000%00
LE6EL II !ospital 7000%00
LE6EL III !ospitals (5eachin$ !ospital) 40000%00
CHECKLIST OF REQUIREMENTSPR6IDER PR*ILE 8PD5E (RECCREDI55I9)
As per Philhealth Circular 11,s. 2013
"7 8it4 'AP 5it43ra5n fro* a,,r3itation!7 Transfr of lo,ation97
A33itional sri,:7 Rs+*-tion of o-ration;7 U-6ra3in6 of Ll7 C4an6 of
o5nrs4i- ( A$C/!DC/Hospitals______ Letter re'uest______ Proof of
chan$e in o"nership (eg. !C, "ee# of ale, "$% Certificate)
$7 C4an6 of o5nrs4i- ( for pri%ate &CP' ) DO$'
A)PP&&&&&& ,ayors Permit
RE'ISTRATION FEEINSTITUTION INITIAL
(Priat 'orn*nt)
Ann+alParti,i-ation
f
SC .000%00 1000%00
(*DC) !D 2 PD .000%00 .000%00
PC3 4000%00 4000%00
53 D5S 4000%00 4000%00
,CP 4.00%00 4000%00PC3/,CP/53D5S
4000%00 4000%00
PC3 / 53 D5S 4000%00 4000%00
PC3/ ,CP 4.00%00 4.00%00
,CP/ 53 D5S 4.00%00 4.00%00
3P 4000%00 4000%00
LE6EL 4 !ospital / Infirmary(& yearsmoratorium)
&000%00
LE6EL II !ospital .000%00
LE6EL II !ospital 7000%00
LE6EL III !os itals 5eachin !os ital 40 000%00
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CHECKLIST OF REQUIREMENTSCCREDI55I9 * !EL5! CRE PR*ESSSI9LS
s per PC .. s% 4 recent pictureo ____ 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 ? 'orn*nt ? RENE8AL
#eneral Practitioner/ &edical $pecialist / Dentist
/&id*ife
CHECKLIST OF REQUIREMENTSCCREDI55I9 * !EL5! CRE PR*ESSSI9LS
s per PC .. s%
