RHUs Form 2 2000

Republic of the Philippines

PHILIPPINE HEALTH INSURANCE CORPORATION

ACCREDITATION DEPARTMENT
12 Floor City State Centre, 709 Shaw Blvd. Oranbo, Pasig City P.O. Box 768 Tel No. 637-62-65 Trunk line 637-99-99 loc 1223, 1216, Telefax. 637-25-27 E-mail: Accre@philhealth.gov.ph

APPLICATION FOR ACCREDITATION ( OUT-PATIENT HEALTHCARE PROVIDER)

_____________, 200_

THE PRESIDENT Philippine Health Insurance Corporation Quezon City, Philippines

SIR: I, ____________________________ , Filipino of legal age, _________________ with address

(Position/ Designation)

at ________________________________________ and the duly authorized representative to act for and in behalf of _____________________________, hereby applies for accreditation
(Health Care Institutions)

under Sec. 16 L of R.A. 7875 and its Implementing Rules and Regulations thereto. For this purpose, I hereby submit the following pertinent information and documentary requirements. PART I GENERAL INFORMATION
Rural Health Unit: _________________________________________________________________ Complete Address: ___________________________________ Postal Code: __________________ Tel No.: __________________________________________________________________________ Date established: ___________________________________________________________________ Tertiary hospital affiliation: __________________________________________________________ District hospital affiliation: ___________________________________________________________ Municipal Health Officer: ____________________________________________________________

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Accreditation Department Application Form 2000

A.

Clinic Facilities General Infrastructure 1. Building ( ) Concrete ( ) Semi-concrete ( ) Wood ( ) Old Structure ( ) Renovated ( ) New structure Sanitation and safety standards a. Water supply _______________________ b. Electric power ______________________ c. Covered garbage containers with color coded segregation Clinic condition ( ) Receiving area ( ) Large and clear sign bearing name of the RHU ( ) Additional sign indicating it as a PhilHealth Medicare Para Sa Masa provider ( ) Generally clean environment ( ) Sufficient seats at waiting area. ( ) <10 ( ) <20 No of seats: ()<5 ( ) Adequate lighting ( ) Examination room with privacy ( ) Examination table with clean linen ( ) Cleaning supplies for the facility and clinical instruments

2.

3.

Equipment and Supplies ( ) Microscope ( ) Centrifuge ( ) Reagents ( ) Glass slides and cover slips ( ) Test tubes ( ) Test strips for qualitative analysis for urine ( ) Applicator stick ( ) Heparinized test tube ( ) Capillette ( ) Blood lancet ( ) Counting chamber ( ) WBC diluting fluid ( ) WBC & RBC diluting pipette ( ) Sucking tube ( ) Thermometer ( ) Stethoscopes ( ) Sphygmomanometer ( ) Tape measure ( ) Weighing scales ( ) Beam scale ( ) Ming scale ( ) Disposable gloves in examining rooms ( ) Speculums ( ) large ( ) small ( ) Lubrication jelly ( ) Disposable needle and syringes ( ) Sharps containers ( ) Sterile cotton and swabs ( ) Covered pan and stove ( ) Patient record forms ( ) Inventory logbooks ( ) Decontamination solutions

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Accreditation Department Application Form 2000

CLINIC STAFF Name Physician Nurse Midwife Med. Tech. PRC No. Validity PHIC No. Validity Signature

B.

SERVICE CAPABILITY Medical Consultation in : ( ) Pediatrics ( ) Internal Medicine ( ) OB-Gyne ( ) Minor Surgery

Diagnostic Services Laboratory Examination: ( ) CBC ( ) Urinalysis ( ) Fecalysis

( ) Sputum microscopy

( ) Chest X-ray Examination Referred to: ____________________________

Name & Address of Facility

C.

QUALITY ASSURANCE ACTIVITIES (OPTIONAL serves as survey only) Check any of the following activity if available: Quality assurance documents: REMARKS ( ) Quality assurance handbook ( ) Mission/Vision ( ) Annual report ( ) Action plans Leadership capability ( ) Medical management ( ) Financial management a) Involvement in budget preparation b) Financial reports ( ) Supervision/Managerial a) Regular staff meetings on clinic management Process control based on standards ( ) Standards for specific management (CPG) a) Posters on treatment protocols (e.g. Diarrhea, Rabies, Pneumonia, etc) ( ) Standards for patient education a) Brochures b) Mothers class ( ) Standards for referral a) Referral forms ( ) Training on Rational Drug Use

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Accreditation Department Application Form 2000

Human Resource Management ( ) Training/ education of management ( ) Continuous education based on priorities ( ) Participation in QA activities within regular working hours ( ) Systematic feedback to RHU Staff Quality Improvement Procedures ( ) Satisfaction survey among patients ( ) Satisfaction survey among employees ( ) Utilization of individual care plans ( ) Management Information system

I hereby declare under penalties of perjury that the answers given are true and correct to he best of my knowledge and belief

______________________________ Date Accomplished

___________________________ Municipal Mayor

Res. Cert. No. ____________ Issued at: _______________ Issued on : ______________

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Accreditation Department Application Form 2000

WARRANTIES OF ACCREDITATION 1. ELIGIBILITY: 1.1 All RHUs and Health Centers are qualified to apply for accreditation under the Out Patient Benefit Package. 1.2 That it is affiliated with a PHIC accredited secondary hospital, or a licensed X-Ray facility for chest x-ray examination of the member of this program. 1.3 That it has the human resources, equipment, physical structure and other requirements in conformity with standards established by the Corporation. 1.4 That it has a licensed physician, nurse, midwife and medical techonologist. 2. COMPLIANCE TO PERTINENT LAWS 2.1 That the aforenamed Rural Health Unit shall in the course of its participation with the NHI program by virtue of its accreditation comply with the provisions of the National Health Insurance Law (RA 7875), its Implementing Rules and Regulations, and all administrative orders of the Corporation. 2.2 That it shall accept the formal program of quality assurance, payment mechanism and utilization review of the NHI Program, 2.3 That its personnel shall strictly adhere and comply at all times with the Codes of Ethics of their profession and other related professions of the Philippines. 3. CLINICAL SERVICES 3.1 That the aforenamed health care institution shall guarantee safe, adequate and standard medical care,and shall exercise observance of public health measures in case of communicable disease, 3.2 That it shall adopt referral protocols, strictly follow guidelines and health resource sharing arrangements of the Program, 3.3 That it shall extend without delay chargeable benefits due qualified members and beneficiaries, 3.4 That it shall not engage in unethical and illegal solicitation of patients for purposes of compensability under the NHI Program, 3.5 That it shall maintain serviceable equipment facilities and required personnel. 4. CLINICAL RECORDS AND PREPARATION OF CLAIMS 4.1 That the aforenamed health care institution shall maintain and accomplish at all times accurate chronological records of all patients, services rendered, health outcomes resulting from such services and health expenditures on patient care, 4.2 That it shall keep a neat and systematic records file in a safe but accessible place for easy retrieval, 4.3 That it shall undertake measures to enter only true and correct data in the duly accomplished forms as required by this Corporation needed prior to the release of the next quarters capitation fund 4.4 That I, acting on behalf of this institution, together with the concerned personnel, shall take full responsibility for any omission or commission in the preparation of claims for capitation fund and in the entry of clinical records. 5. MANAGEMENT INFORMATION SYSTEM 5.1 That the aforenamed health care institution shall give proper information of its accreditation status by posting the Philhealth certificate of accreditation in a very conspicuous place in the said institution, 5.2 That it shall post updated information of the Programs benefits and procedural requirements and make available the necessary forms for patients use, 5.3 That it shall inform the Department of Health all reportable cases referred in the aforenamed institution, 5.4 That it shall immediately inform the Philhealth in writing closure or temporary cessation of the RHUs / Health Centers operation

6. RHU INSPECTION/VISITATION/INVESTIGATION 6.1 That the aforenamed RHU/ Health Center recognizes the authority of Philhealth and its duly authorized representative or agents deputized by Philhealth to conduct inspection, visitation of the institution anytime, _____________
Accreditation Department Application Form 2000

6.2 That it shall cooperate in the inspection/visitation/investigation by making ready and available all records (medical and financial) and other pertinent documents, 6.3 That it shall obey without delay summon, subpoena or subpoena duces tecum from the Corporation or Local Health Insurance Office.

Finally, the undersigned hereby affirms that the Philhealth, by virtue of its power under RA 7875 may suspend or revoke the accreditation of this institution if found to have violated any of the provisions of the National Health Insurance Act, or its implementing Rules and Regulations and any of these Warranties of Accreditation.

____________________________________ Municipal Health Officer (Signature Over Printed Name)

WITNESS MY HAND AND SEAL, this ______________ day of ____________________ 2001 at ____________________________________.

_____________________________________________________ Notary Public Until _______________ PTR No.____________ Issued at____________ Issued on____________

Doc. No. ___________ Book No. ___________ Page No. ___________ Series of 2001

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Accreditation Department Application Form 2000

Republic of the Philippines

PHILIPPINE HEALTH INSURANCE CORPORATION

ACCREDITATION DEPARTMENT
12 Floor City State Centre, 709 Shaw Blvd. Oranbo, Pasig City Tel No. 637-62-65 Trunk line 637-99-99 loc 1223, 1216, Telefax. 637-25-27 E-mail: accre@philhealth.gov.ph

Checklist

REQUIREMENTS FOR ACCREDITATION OF RURAL HEALTH UNITS/HEALTH CENTERS

Name of RHU: ____________________________________________________________ Complete Address: ________________________________________________________

A. INITIAL ACCREDITATION OR RE-ACCREDITATION

___ 1. PhilHealth application form properly accomplished and notarized ___ 2. Complete list of staff with respective designations ___ 3. Organizational chart of the RHU ___ 4. Validated Remittance Form I ( RF-1) If the RF1 is not validated, may attach ME-5 Continuation of A: ___ 7. Standard operating procedure (current) ___ 8. Flow chart of activities when the patient visits the HC ___ 9 . Quality Assurance Program, if any ___10. Sentrong Sigla Certification of Department of Health (if available) ___11. Location map of RHU ___12. Memoranda of Agreement (MOA/s): ____ MOA Between LGU and PhilHealth (if available) ____ MOA with referral x-ray facility (if needed) ____ MOA with referral laboratory facility (if needed) ____ Interlocal Health Zone MOA (for RHUs without capability of rendering laboratory examinations) ___13. P 1000.00 Accreditation fee by postal money order payable to Philippine Health Insurance Corporation or cash paid directly to the cashier (accreditation fee is non-refundable) Note: For discount in accreditation fee, please refer to PHIC circ. #29 s. 2004

If no Validated RF1, may submit: Certification of PhilHealth contributions of RHU Staff from MHO/CHO If the current personnel (physician, nurse, medical technologist, and midwife of RHU) are not included in the RF1, any of the following can be submitted: Job description (for DOH representatives) Memorandum of Understanding between LGU and DOH (for physicians who are under the Doctors to the Barrios Program) Contract of employment and M1-5 (for casual employees) Deployment/assignment papers (for CHO/LGU personnel deployed to the RHU) ___ 5. Photographs of RHU/facility (optional) ___ 6. Photographs of complete RHU staff (current)

B. RENEWAL OF ACCREDITATION
____ 1. Submit numbers 1, 2, 3 and 4 documents mentioned above ____ 2. Location map in case RHU transferred to another location ____ 3. P 1,000.00 Accreditation fee by postal money order payable to Philippine Health Insurance Corporation or cash paid directly to the cashier (accreditation fee is non- refundable). Note: For discount in accreditation fee, please refer to PHIC circ. #29 s. 2004

Accreditation Department NDT/MIRF/rmlh/cheklistrev2 021005