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    Checklist For Konsulta Application Final PRO 10

    Uploaded by

    MHO BALIANGAO
    The document provides a checklist of requirements for Konsulta applications to the Philippine Health Insurance Corporation. It lists 11 required documents including a performance commitment signed by authorized representatives, licenses, proof of services, certification of support, payment receipt, non-disclosure agreement, self-assessment tools, photos/videos, staff duties schedule, evacuation plan, and training certificates. All applications will undergo a pre-accreditation survey to validate compliance with accreditation standards.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Checklist For Konsulta Application Final PRO 10

    Uploaded by

    MHO BALIANGAO
    26 views2 pages
    The document provides a checklist of requirements for Konsulta applications to the Philippine Health Insurance Corporation. It lists 11 required documents including a performance commitment signed by authorized representatives, licenses, proof of services, certification of support, payment receipt, non-disclosure agreement, self-assessment tools, photos/videos, staff duties schedule, evacuation plan, and training certificates. All applications will undergo a pre-accreditation survey to validate compliance with accreditation standards.

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    Checklist-for-Konsulta-Application-Final-PRO-10.docx

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    The document provides a checklist of requirements for Konsulta applications to the Philippine Health Insurance Corporation. It lists 11 required documents including a performance commitment signed by authorized representatives, licenses, proof of services, certification of support, payment receipt, non-disclosure agreement, self-assessment tools, photos/videos, staff duties schedule, evacuation plan, and training certificates. All applications will undergo a pre-accreditation survey to validate compliance with accreditation standards.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    26 views2 pages

    Checklist For Konsulta Application Final PRO 10

    Uploaded by

    MHO BALIANGAO
    The document provides a checklist of requirements for Konsulta applications to the Philippine Health Insurance Corporation. It lists 11 required documents including a performance commitment signed by authorized representatives, licenses, proof of services, certification of support, payment receipt, non-disclosure agreement, self-assessment tools, photos/videos, staff duties schedule, evacuation plan, and training certificates. All applications will undergo a pre-accreditation survey to validate compliance with accreditation standards.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    Republic of the Philippines

    PHILIPPINE HEALTH INSURANCE CORPORATION


    REGIONAL OFFICE X
    8f Gateway Tower 2, Limketkai Center, C.M. Recto Ave., Cagayan de Oro City
    Call Center (02) 441-7442
    www.philhealth.gov.ph

    Checklist of Requirements for Konsulta Applications


    Applicant LHIO Staff AQAS Staff

    Submitted/ Verification Verification


    Required Documents Completely
    Filled-up
    (Please Check
    Upon receipt
    (Please
    Check Upon
    (Please Check of
    prior to Application) Receipt of
    submission) Application)
    1 PDR
    2 Performance Commitment (Signed by the 2 Authorized
    Representatives)
    Government: Head of the facility and Local Chief Executive
    Private: Head of the Facility and Chief Executive, Director, or equivalent
    3 Certified True Copies of Updated Licenses, as applicable:
    ● DOH License. As health facility
    ● Laboratory
    ● X-ray
    ● Pharmacy
    Additional Requirements for Private Facilities;
    ● Business/Mayor’s Permit
    ● Certificate of Registration /Professional Tax Receipt
    4 Proof of ECG Services
    5 a. Certification of Service Delivery Support for Referred
    Outsourced Laboratory Services from a Licensed Laboratory or
    Health Facility with Laboratory Services
    b. Certification of Service Delivery Support for Referred
    Outsourced X-ray Services from a Licensed X-ray Facility or
    Health Facility with Licensed X-ray Services
    c. Certification of Service Delivery Support from an
    FDA-Licensed Partner Drug Outlet or Pharmacy
    d. Certification of Service Delivery Support for ECG services
    (if ECG services is not provided by the facility)
    5 Proof of payment of Accreditation Fee (P2000.00) OR#_______
    6 Non-disclosure Agreement (NDA) signed by staff in the
    PhilHealth Konsulta Facility (Annex E)
    7 Self-assessment tool (SAT) (Annex B)
    Annex B1. Health Human Resource Survey Tool for Philhealth Konsulta Facility
    Annex B2. Checklist of Philhealth Konsulta Drugs & Its Preparations
    Annex B3. Checklist of PhilHealth Konsulta Laboratories and Diagnostic Services

    8 Photos and or videos of all requirements identified in the


    Technical Standards for PhilHealth Konsulta Providers
    9 Schedule of Duties of Facility Staff
    10 Evacuation Plan
    11 Training certificate of staff on Direct Sputum Smear Microscopy
    (DSSM)/NTP Microscopy Training
    (can be complied within 3 months)
    Note: All PhilHealth Konsulta applications shall be subjected to pre-accreditation survey to
    validate compliance to all standards for accreditation.

    Evaluated by: Name Signature Date


    Republic of the Philippines
    PHILIPPINE HEALTH INSURANCE CORPORATION
    REGIONAL OFFICE X
    8f Gateway Tower 2, Limketkai Center, C.M. Recto Ave., Cagayan de Oro City
    Call Center (02) 441-7442
    www.philhealth.gov.ph

    LHIO Staff
    AQAS Staff

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