PDR-HF-080323

PROVIDER DATA RECORD (PDR) FOR HEALTH FACILITIES (HFs)

INSTRUCTIONS
TYPE OF TRANSACTION:
1. All information should be written in UPPER CASE/ CAPITAL LETTERS.
2. All fields are mandatory unless indicated otherwise. If the information is not applicable, ☐ Initial
3.
write “N/A.”
For the Latitude and Longitude fields in Section No. 2 (Mailing/Billing Address), kindly provide the
☐ Renewal
official geographic coordinates used in the DOH Health Facility Geographic Form. ☐ Re-accreditation
4. For the name of the Head of Facility (HoF) in Section No. 8 (Name of Head of Facility), only ☐ Update/ Amendment
check the appropriate box if the HoF has no middle name or has a single name (mononym).
5. If Change in HoF is selected under Section No. 12.B (Update/ Amendment), kindly indicate HF PHILHEALTH ACCREDITATION
the contact information, designation, PAN and validity of PAN of the HoF (if applicable) in NUMBER (PAN):
the “TO” column.
6. All transactions under Section No. 12.B (Update/ Amendment) requires no accreditation fee. Not applicable for initial application.

THE PRESIDENT & CEO

Philippine Health Insurance Corporation
Pasig City, Philippines
Sir/Madam:
I, ________________________________________________________, of legal age, _____________________________ with
Name of the Authorized Representative Position/ Designation of the Authorized Representative

address at _______________________________________________________________ and the duly authorized representative to

Address of the Authorized Representative

act for and in behalf of the health facility, hereby submits the following pertinent information and documentary requirements under Section 56

of the Revised Implementing Rules and Regulations of the National Health Insurance Act of 2013 (R.A. No. 7875, as amended by R.A. No. 9241

and 10606).

NAME
1

OF HF:

2MAILING/BILLING
ADDRESS:
Unit/Room Number/Floor, Building Name, Lot/Block/Phase/Number, Street Name, Subdivision, Barangay Name City or Municipality

Province and/or Region ZIP Code

.
Latitude (XX.XXXXX)
.
Longitude (XXX.XXXXX)
3HF CONTACT
INFORMATION:
Landline and/or Mobile Number Official Email Address

4 TIN: PHILHEALTH EMPLOYER NUMBER:

5

6DOH DOH FACILITY CODE:

LTO NUMBER:

VALIDITY: / / / / 7 ACCREDITATION PERIOD

APPLIED FOR: ☐ 3 Years ☐ 2 Years ☐ 1 Year
Start Date (MM/DD/YY) End Date (MM/DD/YY)
8NAME OF HEAD OF
FACILITY (HoF):
☐ ☐
Last Name First Name Extension Middle Name No Middle Name Mononym

HoF CONTACT
INFORMATION: DESIGNATION:
HoF Landline and/or Mobile Number HoF Email Address

- - HoF PAN / / / /
PAN OF HoF: VALIDITY:
Start Date (MM/DD/YY) End Date (MM/DD/YY)

9 HF CATEGORY
☐ Hospital ☐ Primary Care Facility ☐ COVID-19 Testing Laboratory
Level ☐3 ☐2 ☐1 ☐ Birthing Home
Authorized Bed Capacity (ABC): ______________ ☐ RT-PCR ☐ Cartridge-based
With Hospital Extension Facility (HEF)? ☐ Y ☐ N
☐ TB DOTS Clinic ☐ Drug Abuse Treatment &
HEF address (if Y): ☐ Animal Bite Treatment Clinic Rehabilitation Center
_____________________________________ ☐ Family Planning Clinic ☐ DepEd Clinic
_____________________________________ ☐ HIV-AIDS Treatment Hub ☐ Others
_____________________________________ ☐ Rural Health Unit/ Health ___________________________
_____________________________________ Center
_____________________________________
___________________________
☐ City/ Municipal Health Office __________________________
☐ Infirmary ☐ Provincial Health Office ___________________________
☐ Ambulatory Surgical Clinic ☐ Barangay Health Station ___________________________
☐ Dialysis Clinic ☐ Community Isolation Unit ___________________________
☐ Hemodialysis ☐ Peritoneal Dialysis
10 PHILHEALTH BENEFIT PACKAGE/S OFFERED:

☐ Outpatient HIV-AIDS Treatment ☐ COVID-19 Home Isolation Benefit

☐ Outpatient Malaria Treatment
☐ Konsulta MAXIMUM PATIENT LOAD: __________________________________
☐ Family Planning
☐ Animal Bite Treatment ☐ Others
☐ Subdermal Contraceptive Implant
☐ Maternity Care ☐ Non-Scalpel Vasectomy ————————————————————————————
☐ TB-DOTS ☐ IUD Insertion ————————————————————————————
————————————————————————————
This form may be reproduced and is not for sale. Continue at the back.
 PDR-HF-012023

11 NATURE OF OWNERSHIP:
☐ Government ☐ Private
☐ DOH-Retained ☐ State Universities and Colleges ☐ Single Proprietorship ☐ Others
☐ Provincial ☐ Government-owned and/or Controlled Corporation ☐ Partnership
☐ City/ Municipal ☐ Others ☐ Cooperative _____________________________
☐ Foundation
☐ DND ☐ DOJ __________________________________________ _____________________________
☐ Corporation
☐ PNP __________________________________________ _____________________________
Continue on separate Continue on separate
Name/s of the Local Chief Executive/s (if Government): sheet if necessary. Name/s of the Owner/s (if Private): sheet if necessary.
______________________________________________________________________ _________________________________________________________
______________________________________________________________________ _________________________________________________________
______________________________________________________________________ _________________________________________________________
______________________________________________________________________ _________________________________________________________
______________________________________________________________________ _________________________________________________________
______________________________________________________________________ _________________________________________________________
______________________________________________________________________ _________________________________________________________
______________________________________________________________________ _________________________________________________________

12 DETAILS OF THE RE-ACCREDITATION OR UPDATE/AMENDMENT TRANSACTION

A RE-ACCREDITATION
FROM TO
Validity: _____________________

__________________________________________________ __________________________________________________
☐ Transfer of location __________________________________________________ __________________________________________________
☐ Upgrading of facility level or __________________________________________________ __________________________________________________
category
☐ Change in classification __________________________________________________ __________________________________________________
☐ Change in ownership __________________________________________________ __________________________________________________
__________________________________________________ __________________________________________________

☐ Acquisition of additional _____________________________________________________________________________________________________

service capability that _____________________________________________________________________________________________________
would require change in _____________________________________________________________________________________________________
license/ certificate as _____________________________________________________________________________________________________
applicable

☐ Previous accreditation has lapsed/ ☐ Failure to submit the requirements for continuous ☐ Resumption of operation after closure/
Subsequent application was denied accreditation within the prescribed period cessation of operation

BUPDATE/ AMENDMENT FROM TO

Validity: _____________________

☐ Change in name of __________________________________________________ __________________________________________________

health facility __________________________________________________ __________________________________________________
☐ Change in head of facility __________________________________________________ __________________________________________________
☐ Decrease in beds
__________________________________________________ __________________________________________________
☐ Downgrade of category
or hospital level __________________________________________________ __________________________________________________
☐ Change in HF contact __________________________________________________ __________________________________________________
information __________________________________________________ __________________________________________________
☐ Others __________________________________________________ __________________________________________________
_________________________ __________________________________________________ __________________________________________________
_________________________ __________________________________________________ __________________________________________________
_________________________ __________________________________________________ __________________________________________________
_________________________ __________________________________________________ __________________________________________________
_________________________ __________________________________________________ __________________________________________________
_________________________ __________________________________________________ __________________________________________________
_________________________ __________________________________________________ __________________________________________________
__________________________________________________ __________________________________________________

Under penalty of law, I hereby attest that the information provided, including the documents I have attached to this form, are true
and accurate to the best of my knowledge. I agree and authorize PhilHealth for the subsequent validation, verification and for
other data sharing purposes only under the following circumstances:

 As necessary for the proper execution of processes related to the legitimate and declared purpose;
 The use or disclosure is reasonably necessary, required or authorized by or under the law, and;
 Adequate security measures are employed to protect my information.

Authorized Representative’s Signature over Printed Name Date

FOR PHILHEALTH USE ONLY CONTROL N O:

_________________________________________________
Date LHIO/PRO LHIO/PRO
LHIO LHIO Date LHIO LHIO Receiving
Date Encod- PRO By
By Evaluat- By
Received ed Data Entry PRO
PRO PRO ed PRO PRO