X Ray Application Form PDF Details

Applying for or renewing a license to operate a medical X-Ray facility in the Republic of the Philippines involves a comprehensive process, as outlined by the Department of Health's Food and Drug Administration, specifically through its Center for Device Regulation, Radiation Health, and Research (CDRRHR). This process is meticulously designed to ensure that facilities meet the stringent standards set for the operation of medical X-Ray equipment, prioritizing the safety and well-being of both the patients and the personnel involved. The application form, a critical component of this process, requires numerous documents, including two copies of the duly accomplished form, payment of the license application fee, verification of dose monitoring for personnel, and credentials of the radiologists and technologists among others. For renewals, additional requirements include dose evaluation reports and an affidavit of continuous compliance. Training certificates for radiologic technologists and contracts of employment further supplement the application, highlighting the importance of certified professionals in providing quality healthcare. Fees vary depending on the number and type of X-Ray machines, and penalties are imposed for late renewals. The exhaustive checklist and guidelines ensure that every X-Ray facility operates within the regulatory framework, sustaining a high standard of medical care and safety in radiographic services across the country.

QuestionAnswer
Form NameX Ray Application Form
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesapplication form for a license to operate a medical x ray facility, how to renew x ray license online, checklist lto, fda x ray renewal online philippines

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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).

 

 

 

 

 

 

3.

 

Photocopy of the Official Receipt of the personal dose monitor (film,TLD, or OSL) from the

 

 

provider of personnel dose monitoring service. (FOR RENEWAL APPLICATION ONLY)

 

 

 

 

4.

 

Photocopy of the personal dose evaluation reports within the validity period of the previous license

 

 

(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.

 

 

 

 

 

6.

 

Photocopy of the PRC board certificate and a VALID PRC license of the Radiologic/X-ray

 

 

technologist.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7.

 

Certificate of training of the radiologic/x-ray technologist in radiation protection if he/she acts as

 

 

the radiation protection officer.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8.

 

Certificate of training of the head of the facility in radiology if he is not a FPCR/DPBR for

 

 

government facilities and in areas with no FPCR/DPBR within 45 km vicinity radius.

 

 

 

 

 

 

 

 

9.

 

Photocopy of valid notarized contract of employment of the Radiologist and Radiologic/X-ray

 

 

technologist. The CDRRHR recommends that the contract be valid for at least one year.

 

 

 

 

 

 

 

 

10.

 

Duly filled-up and notarized affidavit of continuous compliance (FOR RENEWAL

 

 

 

 

APPLICATION ONLY).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11.

 

Photocopy of the business/mayor’s permit or SEC/DTI registration of the facility (FOR INITIAL

 

 

APPLICANTS AND RENEWAL APPLICANTS WITH NEW ADDRESS).

 

 

 

 

 

 

 

 

12.

 

Photocopy of the latest License to Operate. (FOR RENEWAL APPLICATION ONLY).

 

13.

 

Photocopy of a valid vehicle LTO registration (OR/CR). (FOR TRANSPORTABLE X-RAY

 

 

FACILITIES ONLY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No. of x-ray

 

 

Initial /Renewal

 

 

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: apperalta@co.doh.gov.ph

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

Renewal of LTO#_______

Amendment to existing LTO # ______

Doc. Control No:

 

 

 

 

 

 

 

Reason/s for amendment:____________

__________________

 

 

I

General Information

 

 

 

 

 

 

Name of Facility :__________________________________________________________________

Thru mail

 

 

Facility Address :__________________________________________________________________

Walk-in

 

 

 

 

 

 

 

__________________________________________________________________

Attachments:

 

 

Contact No./s

:__________________________________________________________________

 

 

Check.

 

 

 

 

 

 

 

 

 

 

Name and Address of the Applicant, Legal Person, Company, Organization, etc.

PMO

 

 

No. : ____________

 

 

 

 

 

 

 

 

 

 

Name :_________________________________ Position/Designation :_____________________

Amount: ________ _

 

 

Address : ________________________________________________________________________

 

 

 

Contact No./s:_____________________________

 

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:

 

 

 

 

 

 

 

 

 

 

Name : _________________________________

Name :________________________________

__________________

 

 

Date :_____________

 

 

Qualification :

FPCR

DPBR

Qualification:___________________________

 

 

Time: _____________

 

 

 

 

Others: ________________

 

 

 

 

 

 

SIGNATURE:

Evaluation:

 

 

PRC ID#/ Validity :_______________________

 

 

 

Date Received:______

 

 

 

 

 

 

 

 

 

SIGNATURE:

 

 

 

 

Time: _____________

 

 

 

 

 

Chief Radiologic/X-ray Technologist :

Medical/Health Physicist *

Remarks:

 

 

 

 

 

 

 

 

________________

 

 

Name : ________________________________

Name :________________________________

________________

 

 

Qualification :

RRT

RXT

Qualification:___________________________

________________

 

 

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:

 

 

 

 

 

 

__________________________

__________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Printed Name and Signature

Date:____________

 

 

 

 

 

 

Position:___________________

 

 

 

 

 

 

 

 

Date: _____________________

__________________

 

 

 

 

 

 

 

 

Encoded by:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date:______________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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: apperalta@co.doh.gov.ph

Page 1 of 2

 

IV

Equipment Specifications (All x-ray equipment in diagnostic and/ or interventional radiology facility)

*Type

Name of

Manufacturer

 

Brand

 

Model

Serial Number

Tube

 

Control

Tube

 

Control

Tube

Control

head

 

Console

head

 

Console

head

Console

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Max. kVp

Max. mA

**Location

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

 

VName and qualifications of other radiologists and radiologic/x-ray technologists working in the diagnostic and/ or interventional radiology facility

Name

Designation

Qualification

PRC

License

Validity

Signature

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:

Name

Designation

Qualification

PRC

License

Validity

Signature

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:

Chest for Heart and Lungs

Vertebral Column

Shoulder Girdle

Extremities

Localization of Foreign Body

Thoracic Cage

Skull

Pelvis

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:

Upper G.I. series

Esophagography[Ba. Swallow]

Paranasal Sinuses

Small Intestinal Series

Pelvimetry

Scoliotic Series

Barium Enema

Fetography

Skeletal Survey

Hysterosalpingography

Cardiac Studies with Barium

Imperforated Anus

Oral Cholegraphy

Myelography

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

Page 2 of 2

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Part # 1 in submitting fda x ray application form

2. After the last part is completed, you need to put in the necessary details in License application fee refer to, Photocopy of the latest License, Photocopy of a valid vehicle LTO, Schedule of Fees Section of DOH, No of xray, Machines, mA range, Initial Renewal, with, surchargePHP, and below up to up to up to, greater than, RenewalPHP, Renewal with, and TOTAL so you can move forward further.

fda x ray application form completion process explained (step 2)

3. This next section will be focused on TYPE OF AUTHORIZATION, New application, Renewal of LTO, Amendment to existing LTO, II Name and qualifications of the, Head of the Facility Radiologist, FPCR Others, DPBR, SIGNATURE, Chief RadiologicXray Technologist, RRT, Radiation Protection Officer Name, SIGNATURE, MedicalHealth Physicist Name, and For CDRRHR use Doc Control No - fill out all these empty form fields.

Chief RadiologicXray Technologist, MedicalHealth Physicist  Name, and Amendment to existing LTO inside fda x ray application form

4. Filling out Chief RadiologicXray Technologist, RRT, SIGNATURE, MedicalHealth Physicist Name, SIGNATURE if available, III Declaration of the veracity of, Remarks, Recommending Approval Date, Date, cid, Trunk Line local Telefax cid, Bldg San Lazaro Compound Rizal, and Page of is vital in this fourth form section - ensure to invest some time and fill in each and every empty field!

Chief RadiologicXray Technologist, Recommending Approval  Date, and Trunk Line  local  Telefax  cid in fda x ray application form

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