<p> Republic of the Philippines Department of Health HEALTH FACILITIES AND SERVICES REGULATORY BUREAU</p><p>HFS Change Request Form </p><p>Date: </p><p>Name of Health Facility/Service</p><p>Address : No. & Street Barangay</p><p>City/Municipality Province Region</p><p>Latest LTO/COA/ATO/COR No. Validity Period from to </p><p>Tel. Number (HF landline) Cellphone No. E-Mail Address</p><p>Owner </p><p>Permit to Construct No. (if applicable) Type of Health Facility/Service: License to Operate:</p><p>[ ] Ambulatory Surgical Clinic Ambulance Service Provider [ ] [ ] Birthing Home Ambulance, specify no. of vehicle/s as approved_____ [ ] Blood Bank [ ] Clinical Laboratory [ ] Dental Laboratory [ ] Dialysis Clinic [ ] HIV Testing Laboratory [ ] Hospital [ ] General Level 1 Level 2 Level 3 [ ] Specialty, Specify ______[ ] Infirmary [ ] Psychiatric Care Facility Certificate of Accreditation: Certificate of Registration: [ ] Blood Center [ ] Special Clinical Laboratory [ ] Drug Abuse Treatment and Rehabilitation Center [ ] Kidney Transplant Facility Authority to Operate: [ ] Laboratory for Drinking Water Analysis [ ] Blood Collection Unit [ ] Medical Facility for Overseas Workers and Seafarers [ ] Blood Station [ ] Newborn Screening Center </p><p>[ ] Human Stem Cell & Cell-Based or Cellular Therapy </p><p>[ ] Occupational Establishment Dental Clinic </p><p>[ ] Private School Dental Clinic</p><p>Nature of Request/Change/Transaction (Please check [√ ] appropriate box). Change in ABC from to Change in type of facility Change in number of dialysis station from _ t to Change in classification (function, institutional character) Change in number of ambulance vehicle from Change in Name to to Hospital upgrading from to Change in ownership Hospital downgrading from to Change/Additional personnel Transfer of location Change/Additional equipment Closure of the facility, specify effective date______Change in service/s Other transaction, specify Form-HFS-CR-A Additional service/s Revision:00 03/30/2017 Page 1 of 1 Note: Attached documentary requirements with change/s Details of Request</p><p>Signature over printed name of Director/Owner Date: </p><p>Recommendation: Date:______For inspection For submission of documents For issuance of LTO/COA/ATO/COR</p><p>Recommended by: Approved by:</p><p>Print Name and Signature</p><p>Form-HFS-CR-A Revision:00 03/30/2017 Page 2 of 1</p>