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Initial/Re-accreditation: Citystate Centre Building, 709 Shaw Boulevard, Pasig City Healthline 441 7444

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San Juan Mho
The document is a statement of intent form from the Philippine Health Insurance Corporation for health facilities applying for initial accreditation or re-accreditation. It provides two options for applicants filing their applications in the last quarter of the year. Option A agrees to pay the accreditation fee for the full cycle and have accreditation start before January 1 if requirements are met. Option B agrees to pay the full fee but have accreditation start on January 1 of the following year. The applicant must sign the option they agree with.

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23 views1 page

Initial/Re-accreditation: Citystate Centre Building, 709 Shaw Boulevard, Pasig City Healthline 441 7444

Uploaded by

San Juan Mho
The document is a statement of intent form from the Philippine Health Insurance Corporation for health facilities applying for initial accreditation or re-accreditation. It provides two options for applicants filing their applications in the last quarter of the year. Option A agrees to pay the accreditation fee for the full cycle and have accreditation start before January 1 if requirements are met. Option B agrees to pay the full fee but have accreditation start on January 1 of the following year. The applicant must sign the option they agree with.

Copyright:

© All Rights Reserved

Available Formats

Download as PDF, TXT or read online on Scribd
Download as pdf or txt
Download as pdf or txt
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RepublicofthePhilippines

PHILIPPINEHEALTHINSURANCECORPORATION

CitystateCentreBuilding,709ShawBoulevard,PasigCity
Healthline4417444www.philhealth.gov.ph

STATEMENT OF INTENT

Initial/Re-accreditation

Date: ________________________
Name of Institution: ______________________________
Address: __________________________________________
Sign the applicable items if you agree with the statements below:
1. For applications for Initial Accreditation or Re-accreditation that are filed during
the last quarter of the current year:
OPTION A: I agree with the following provisions:
1. To pay the accreditation fee equivalent to one (1) accreditation cycle and the start date
of accreditation of our health facility shall be before January 1 when it has complied
with the requirements for accreditation.
2. I agree that in case, my application is only approved by the Corporation after
December 31st of the current year, I shall submit my application for continuous
accreditation within 30 days from receipt of the approval letter.
___________________________
Signature over Printed Name of the
Authorized Person
OPTION B: I agree with the following provisions:
1. To pay the accreditation fee equivalent to one (1) accreditation cycle and that the start
date of accreditation of our health facility shall be on January 1 of the succeeding year.
___________________________
Signature over Printed Name of the
Authorized Person

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