Republic of the Philippines

DEPARTMENT OF HEALTH

ORDER OF PAYMENT
NON-HOSPITAL BASED NON-OSS HEALTH FACILITIES AND SERVICES
Date: ________________________
NAME OF HEALTH FACILITY: _________________________________________________________________________________
AO 2016-0029 AnnxE dtd
ADDRESS:_________________________________________________________________________________________ 6/29/2016 Ambulance
AO 2012-0012 dtd
7/18/2012;AO 2008-0007 dtd.
To CASHIER: Please charge the amount of ___________________________________________________________________ (Php ____________) for: AO 2008-0008 dtd3/14/08
(CL)
5/2/2008-
BSF; AO 2007-0001 dtd.
(Please check the appropriate box) 5/5/07

LICENSE TO OPERATE CERTIFICATE OF ACCREDITATION

Initial Renewal Remarks Initial Renewal Remarks
renewal- DRUG ABUSE TREATMENT AND REHABILITATION renewal-every
AMBULATORY SURGICAL CLINIC 14,000.00 14,000.00 every 3 yrs. CENTER -RESIDENTIAL 14,000.00 14,000.00 3 yrs.

w/ 10% disc. 12,600.00 20,000.00 CASH BOND

renewal-
BLOOD CENTER 5,000.00 5,000.00 every 3 yrs. w/ 10% disc. 12,600.00
w/ 10% disc. 4,500.00
DRUG ABUSE TREATMENT AND REHABILITATION renewal-every
CENTER - NON RESIDENTIAL 6,000.00 6,000.00 3 yrs.
renewal-
DIALYSIS CLINIC (FS) 9,500.00 9,500.00 every 3 yrs.
20,000.00 CASH BOND

w/ 10% disc. 8,550.00 w/ 10% disc. 5,400.00

renewal- HUMAN STEMCELL & CELL-BASED OR CELLULAR renewal-every
*CLINICAL LABORATORY (GENERAL) every year
THERAPY 38,000.00 38,000.00 year
Primary 2,500.00 2,000.00 w/ 10% disc. 34,200.00
renewal-every
w/ 10% disc. 1,800.00 KIDNEY TRANSPLANT FACILITY 38,000.00 38,000.00 3 yrs.
Secondary 3,000.00 2,500.00 w/ 10% disc. 34,200.00
LABORATORY FOR DRINKING WATER ANALYSIS renewal-every
w/ 10% disc. 2,250.00 (FS) 5,000.00 5,000.00 3 yrs.
w/ 10% disc. 4,500.00
renewal-every
Tertiary 3,500.00 3,000.00 NEWBORN SCREENING CENTER 8,500.00 8,500.00 3 yrs.
w/ 10% disc. 2,700.00 w/ 10% disc. 7,650.00
Limited Service Capability 2,500.00 2,000.00 DRUG ABUSE TREATMENT AND REHABILITATION CENTER PERSONNEL:

w/ 10% disc. 1,800.00 Physician 1,000.00 1,000.00

* Clinical Laboratory includes HIV testing and water-testing services as well as blood
service facilities. Other Professional 500.00 500.00
Non-Professional 500.00 500.00
PSYCHIATRIC CARE FACILITY renewal-
REGISTRATION FEE 200.00 every year AUTHORITY TO OPERATE
ACUTE-CHRONIC PCF 7,500.00 5,500.00 BCU 1,500.00 1,500.00
renewal-every
w/ 10% disc. 4,950.00 w/ 10% disc. 1,350.00 3 yrs.
CUSTODIAL PCF 6,000.00 4,000.00 BS 1,400.00 1,400.00
w/ 10% disc. 3,600.00 w/ 10% disc. 1,260.00
BIRTHING HOME (DOH-RO) renewal-
BCU/BS 1,500.00 1,500.00
REGISTRATION FEE 200.00 every year w/ 10% disc. 1,350.00
4,500.00 3,000.00 for govt & CERTIFICATE OF REGISTRATION
private CLINICAL LABORATORY (SPECIAL) 200.00
w/ 10% disc. 2,700.00 Specify type of lab service/s ____________________________

renewal- Surcharge Fee = 50% of the renewal LTO/CoA if filed

every year after expiration date
INFIRMARY (DOH-RO) 6,000.00 5,500.00
w/ 10% disc. 4,950.00
renewal- Re-Inspection/Re-Survey Fee = 100% of the LTO/CoA
Ambulance Service Provider 15,000.00 15,000.00 every 3 years
both initial and renewal
renewal-
Ambulance 3,000.00 per unit every 3 years Other Fees, specify ___________

Ambulance Service Provider 5,000.00 5,000.00 renewal CERTIFICATION as Registered HF 50.00

yearly
Ambulance 1,000.00 per unit
Sub- Total Php GRAND TOTAL Php
Prepared by: Received the above payment/s:
Name/Signature: ___________________
Licensing Officer/Designate Staff Amount: __________________
Cash/PMO/Check. No. Issued ______________ Date :_______________
OR No. Issued: _______________
Date Issued: ________________ Form OP 04 (NHB-OTHER HF)

Revision:08

08/09/2017