Application Form Clinical Laboratory PDF
Application Form Clinical Laboratory PDF
Application Form Clinical Laboratory PDF
Department of Health
HEALTH FACILITIES AND SERVICES REGULATORY BUREAU
Classification According to
A B C
Documents For Initial For Renewal
1. Notarized Application for License to Operate a Clinical Laboratory (this form)
Submit
2. List of Personnel (attached form)
changes only
3. Photocopies of the following:
3.1. Proof of qualification of the medical and paramedical staff
Valid PRC ID
Specialty Board Certificate of the medical staff
Certificate of Training/ Record of Work Experience
3.2. Proof of employment of the medical, paramedical and administrative staff
3.3. Current Authority to Practice for government pathologists (AO No. 161 s. 2000)
Submit
4. List of Equipment/ Instrument (attached Form)
changes only
5. Health Facility Geographic Form (Location Map)
6. SEC/ DTI Registration (for private clinical laboratories) OR
Issuance or Board Resolution (for government clinical laboratories)
Submit
7. Quality Manual of Clinical Laboratory (to be fully implemented by January 2009)
changes only
8. Certificate of Participation in External Quality Assurance Program
Form-GCL-LTO-A
Revision:01
12/03/2014
Page 1 of 5
Acknowledgement
documents required for the Licensure and Regulation of Clinical Laboratories in the Philippines pursuant to Administrative
Order No. 2007-0027 Revised Rules and Regulations Governing the Licensure and Regulation of Clinical Laboratories in
the Philippines.
_________________________
Signature
known to me to be the same person/s who executed the foregoing instrument and they acknowledge to me that the same is
The Director
DOH-Regional Office
Department of Health
Sir,
In compliance with the requirements of Republic Act (RA) No. 4688 and Administrative Order
(AO) No. 2007-0027, I have the honor to apply as head of:
_________________________________________
Name of Clinical Laboratory
_________________________________________
Address of Clinical Laboratory
I hereby certify that the foregoing statements are true. I assume full responsibility that the
operation of the clinical laboratory is in accordance with the Rules and Regulations pursuant
to RA 4688 and AO No. 2007-0027.
______________________________
Signature over Printed Name
___________________
Date
Annex A
Name of Laboratory : _______________________________________________________________________________________
Address of Laboratory : _______________________________________________________________________________________
Annex B
Name of Laboratory : _______________________________________________________________________________________
Address of Laboratory : _______________________________________________________________________________________