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RHUs Form 22000

Republic of the PhilippinesPHILIPPINE HEALTH INSURANCE CORPORATIONACCREDITATION DEPARTMENT 12 Floor City State Centre, 709 Shaw Blvd. Oranbo, Pasig City P.O. Box 768Tel No. 637-62-65 Trunk line 637-99-99 loc 1223, 1216, Telefax. 637-25-27

E-mail: [email protected]

APPLICATION FOR ACCREDITATION( OUT-PATIENT HEALTHCARE PROVIDER)

_____________, 200_

THE PRESIDENTPhilippine 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: ____________________________________________________________

_____________ Accreditation DepartmentApplication Form 2000

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A. Clinic Facilities

General Infrastructure

1. Building( ) Concrete( ) Semi-concrete( ) Wood ( ) Old Structure

( ) Renovated ( ) New structure

2. Sanitation and safety standardsa. Water supply _______________________

b. Electric power ______________________ c. Covered garbage containers with color coded segregation

3. 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.

No of seats: ( ) < 5 ( )

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CLINIC STAFF

Name PRC No. Validity PHIC No. Validity SignaturePhysician

NurseMidwifeMed. Tech.

B. SERVICE CAPABILITY

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

Diagnostic Services

Laboratory Examination:

( ) CBC ( ) Chest X-ray Examination Referred ( ) Urinalysis to: ____________________________ ( ) Fecalysis Name & Address of Facility ( ) Sputum microscopy

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/Manageriala) 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 referrala) Referral forms

( ) Training on Rational Drug Use

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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 myknowledge and belief

______________________________ ___________________________ Date Accomplished Municipal Mayor

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

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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-rayexamination of the member of this program.

1.3 That it has the human resources, equipment, physical structure and other requirements in conformity withstandards established by the Corporation.

1.4 That it has a licensed physician, nurse, midwife and medical techonologist.

2. COMPLIANCE TO PERTINENT LAWS2.1 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 reviewof 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 SERVICES3.1 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 CLAIMS4.1 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 theentry of clinical records.

5. MANAGEMENT INFORMATION SYSTEM5.1 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/INVESTIGATION6.1 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 institutionanytime,

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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 maysuspend 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 PublicUntil _______________ PTR No.____________ Issued at____________ Issued on____________

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

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ChecklistRepublic of the PhilippinesPHILIPPINE HEALTH INSURANCE CORPORATION ACCREDITATION DEPARTMENT

12 Floor City State Centre, 709 Shaw Blvd. Oranbo, Pasig CityTel No. 637-62-65 Trunk line 637-99-99 loc 1223, 1216, Telefax. 637-25-27

E-mail: [email protected]

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 Continuation of A:

___ 2. Complete list of staff with respective designations ___ 7. Standard operating procedure (current)

___ 3. Organizational chart of the RHU ___ 8. Flow chart of activities when the patient visits the HC

___ 4. Validated Remittance Form I ( RF-1) ___ 9 . Quality Assurance Program, if any

If the RF1 is not validated, may attach ME-5 ___10. Sentrong Sigla Certification of Department of Health (if

If no Validated RF1, may submit: available)

Certification of PhilHealth contributions of RHU Staff from ___11. Location map of RHU

MHO/CHO

If the current personnel (physician, nurse, medical technologist, ___12. Memoranda of Agreement (MOA/s):

and midwife of RHU) are not included in the RF1, any of the ____ MOA Between LGU and PhilHealth (if available)following can be submitted: ____ MOA with referral x-ray facility (if needed) Job description (for DOH representatives) ____ MOA with referral laboratory facility (if needed)

Memorandum of Understanding between LGU and DOH (for ____ Interlocal Health Zone MOA (for RHUs without

physicians who are under the Doctors to the Barrios Program) capability of rendering laboratory examinations)

Contract of employment and M1-5 (for casual employees) ___13. P 1000.00 Accreditation fee by postal money order

Deployment/assignment papers (for CHO/LGU personnel payable to Philippine Health Insurance Corporation or

deployed to the RHU) cash paid directly to the cashier (accreditation fee is

___ 5. Photographs of RHU/facility (optional) non-refundable)

___ 6. Photographs of complete RHU staff (current)Note: For discount in accreditation fee, please refer to PHIC circ.

#29 s. 2004

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 toPhilippine Health Insurance Corporation or cashpaid directly to the cashier (accreditation fee is non- refundable).

Note: For discount in accreditation fee, please refer to PHIC circ. #29 s.

2004

Accreditation DepartmentNDT/MIRF/rmlh/cheklistrev2 021005

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