Republic of the Philippines

Department of Health
Food and Drug Administration
CENTER FOR DEVICE REGULATION,
RADIATION HEALTH, AND RESEARCH

CHECKLIST OF REQUIREMENTS FOR INITIAL ISSUANCE / RENEWAL OF

A LICENSE TO OPERATE (LTO) A MEDICAL X-RAY FACILITY

1. Duly accomplished x-ray application form (2 copies).

License application fee (refer to the schedule of fees below). For mailed applications, Postal Money
2. Order or Manager’s Check shall be payable to the FOOD AND DRUG ADMINISTRATION
(PMO Address: Alabang Muntinlupa).
Photocopy of the Official Receipt of the personal dose monitor (film,TLD, or OSL) from the
3.
provider of personnel dose monitoring service. (FOR RENEWAL APPLICATION ONLY)
Photocopy of the personal dose evaluation reports within the validity period of the previous license
4.
(FOR RENEWAL APPLICATION ONLY)
Photocopy of the certificate of the radiologist for being a Fellow of the Philippine College of
5. Radiology (FPCR) or Diplomate of the Philippine Board of Radiology (DPBR) and a VALID
Professional Regulation Commission (PRC) license.
Photocopy of the PRC board certificate and a VALID PRC license of the Radiologic/X-ray
6.
technologist.
Certificate of training of the radiologic/x-ray technologist in radiation protection if he/she acts as
7.
the radiation protection officer.
Certificate of training of the head of the facility in radiology if he is not a FPCR/DPBR for
8.
government facilities and in areas with no FPCR/DPBR within 45 km vicinity radius.
Photocopy of valid notarized contract of employment of the Radiologist and Radiologic/X-ray
9.
technologist. The CDRRHR recommends that the contract be valid for at least one year.
Duly filled-up and notarized affidavit of continuous compliance (FOR RENEWAL
10.
APPLICATION ONLY).
Photocopy of the business/mayor’s permit or SEC/DTI registration of the facility (FOR INITIAL
11.
APPLICANTS AND RENEWAL APPLICANTS WITH NEW ADDRESS).
12. Photocopy of the latest License to Operate. (FOR RENEWAL APPLICATION ONLY).
Photocopy of a valid vehicle LTO registration (OR/CR). (FOR TRANSPORTABLE X-RAY
13.
FACILITIES ONLY)

Schedule of Fees (Section 1 of DOH Administrative Order No. 29, s. 2000)

Initial /Renewal
No. of x-ray Renewal with 50% TOTAL
mA range with 100% Renewal(PHP)
Machines surcharge(PHP) FEE
surcharge(PHP)
100 and below 800 400 600
101 up to 300 1100 550 825
301 up to 500 1400 700 1050
501 up to 700 1700 850 1275
greater than 700 2000 1000 1500

Sections 12.3 and 12.4 of the DOH AO No. 124, s. 1992, penalties for late renewal of x-ray license are as follows:
50% surcharge if application for renewal is filed within three (3) months after the expiration of license
100% surcharge is application for renewal is filed after three (3) months after expiration of license

REMINDERS:
1. Incomplete requirements shall not be processed.
2. For initial/renewal application, fee paid shall be forfeited when the facility fails to comply with the licensing
requirements within 60 days upon proper notice from the CDRRHR. (Section 5 item no. 2 of the Bureau
Order No. 005 s. 2005)

Bldg. 24, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila ●
Trunk Line 651-7800 local 3409 Telefax: 711-6016 ● URL: http://www.doh.gov.ph; e-mail: [email protected]
 Republic of the Philippines
Department of Health
Food and Drug Administration
CENTER FOR DEVICE REGULATION,
RADIATION HEALTH, AND RESEARCH

Document No.:x 011-003-001-Annex-2.1

Revision:x 00

APPLICATION FORM FOR A LICENSE TO OPERATE A MEDICAL X-RAY FACILITY

General Instructions: Write legibly and in BLOCK letters. Put an “x” mark on appropriate tick box. Completely fill-up
the required information and signatures. The CDRRHR will not receive and process unduly filled-up application forms.
For requirements, please refer to the attached checklist.

TYPE OF AUTHORIZATION For CDRRHR use

New application x Renewal of LTO#_______
09-27-18-32-H1-2 Amendment to existing LTO # ______ Doc. Control No:
Reason/s for amendment:____________ __________________
I General Information
OSPITAL NG KABATAAN NG DIPOLOG, INC.
Name of Facility :__________________________________________________________________ Thru mail
604 PADRE RAMON STREET, ESTAKA, DIPOLOG CITY, ZAMBOANGAE DEL NORTE
Facility Address :__________________________________________________________________ Walk-in
__________________________________________________________________
Attachments:
Contact No./s 212 - 2837
:__________________________________________________________________ Check.
PMO
Name and Address of the Applicant, Legal Person, Company, Organization, etc. No. : ____________
DR. PACITA I. FRANCO, FPPS,FPSHBT,FPSPH Position/Designation :_____________________
Name :_________________________________ HOSPITAL ADMIN / MED.DIRECTOR Amount: ________ _
604 Padre Ramon St., Estaka, Dipolog City, Zamboanga Del Norte
Address : ________________________________________________________________________
212 - 2837
Contact No./s:_____________________________ [email protected]
Email Address : ______________________ Fee Paid
PHP:______________
O.R #_____________
II Name and qualifications of the personnel working in the medical x-ray facility Date Paid __________
Head of the Facility (Radiologist) : Radiation Protection Officer
Received by:
IDA JOSEFA O. GERONIMO,MD,FPCR,FCTMRISP,FUSP IDA JOSEFA O. GERONIMO, MD,FPCR,FCTMRISP,FUSP __________________
Name : _________________________________ Name :________________________________
Date :_____________
Qualification : x FPCR DPBR RADIOLOGIST
Qualification:___________________________ Time: _____________
Others: ________________ SIGNATURE: Evaluation:
0066332 / JULY 2021
PRC ID#/ Validity :_______________________ Date Received:______
SIGNATURE: Time: _____________
Chief Radiologic/X-ray Technologist : Medical/Health Physicist * Remarks:
________________
CHRISTINA ANNA R. VERDEFLOR
Name : ________________________________ N/A
Name :________________________________ ________________
Qualification : X RRT RXT Qualification:___________________________ ________________
0004345 / DEC.2018
PRC ID#/Validity : ______________________ ________________
SIGNATURE:
________________
SIGNATURE:
________________
*if available
________________
III Declaration of the veracity of information: To be signed by the legal person/owner
________________
________________
I hereby declare that all the information provided on the form and in support of this application
is to the best of my knowledge complete and true in every particular.
Recommending
Approval:
DR.PACITA I. FRANCO, FPPS, FPSHBT, FPSPH
__________________________ __________________
Printed Name and Signature Date:____________
HOSPITAL ADMIN. / MEDICAL DIR.
Position:___________________
AUGUST 29, 2018
Date: _____________________ __________________
Encoded by:

Date:______________

Bldg. 24, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila ● Page 1 of 2
Trunk Line 651-7800 local 3409 Telefax: 711-6016 ● URL: http://www.doh.gov.ph; e-mail: [email protected]
 IV Equipment Specifications (All x-ray equipment in diagnostic and/ or interventional radiology facility)

Brand Model Serial Number

Name of Max. Max.
* Type Tube Control Tube Control Tube Control **Location
Manufacturer kVp mA
head Console head Console head Console
CARESTREAM CARESTREAM X-RAY DEPARTMENT
(ODYSSEY HF SERIES) ( TOSHIBA ) 6K0987 QG4000-17R-0301 125 kVp 500 mA GRROUND FLOOR

Please use separate sheet if necessary

* For Type, indicate whether ** For Location, indicate location of x-ray machine such as :
- Radiography (Mobile/Stationary) - Lithotripsy - Radiology Department (Room 1,2,3 etc.)
- Mobile C-Arm Fluoroscopy - Mammography - 1st Floor, 2nd Floor, etc.
- Bone Densitometry - Computed Tomography
- Radio-fluoroscopy (Stationary) - Simulator

V Name and qualifications of other radiologists and radiologic/x-ray technologists working in the diagnostic
and/ or interventional radiology facility
PRC
Name Designation Qualification Validity Signature
License
REGISTERED X-RAY
MERVIN JAY A. ABREU X-RAY TECH. TECHNOLOGIST 06158 MARCH 2020
KATE MIKEE M. ELIA RAD TECH REGISTERED RADIOLOGIC 0019260 MARCH 2023
TECHNOLOGIST

Please use separate sheet if necessary

VI Name and qualifications of other medical practitioners (i.e. nurses, cardiologist, interventionalist, etc.)
working in the diagnostic and/or interventional radiology facility:
PRC
Name Designation Qualification Validity Signature
License

Please use separate sheet if necessary

VII X-ray Service Category: (Tick appropriate radiology services)

General Radiography
Level One x-ray facility which is capable of performing the following non-contrast radiographic examinations:
X Chest for Heart and Lungs X Vertebral Column X Shoulder Girdle

X Extremities X Localization of Foreign Body X Thoracic Cage

X Skull X Pelvis X Abdomen
Level Two x-ray facility which is capable of performing examinations done in the primary category and the following non-contrast
and contrast radiographic examinations:
X Upper G.I. series X Esophagography[Ba. Swallow] X Paranasal Sinuses

X Small Intestinal Series Pelvimetry X Scoliotic Series

X Barium Enema Fetography X Skeletal Survey
Hysterosalpingography Cardiac Studies with Barium Imperforated Anus
Oral Cholegraphy Myelography X Intravenous Pyelography
Level Three x-ray facility which is capable of performing examinations done in the primary and secondary categories and the
following invasive procedures:
Sinugraphy Tomography All Non-Cardiac Percutaneous Procedures
Fistulography Pacemaker Implants Visceral & Peripheral Angiography
Sialography Retrograde Cystography Operative & Post-operative Cholangiography
Bronchography Cerebral Angiography Endoscopic Retro. Cholangio. Pancreatography
Retrograde Urography Lymphography/Lympangiography
Specialized Diagnostic and Interventional X-ray Services
Computed Tomography Mammography Digital Subtraction Angiography
Lithotripsy Bone Densitometry Percutaneous Transluminal Angioplasty
Cardiac Catheterization Tumour Localization and simulation

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