INSTRUCTIONS

In filling-up the x-ray license application form, the instructions enumerated below must be followed.
Failure to do so may cause unnecessary delays in the processing of your license.
1.

Three (3) copies of properly filled-up application form including the original copy must be submitted.

2.

Page 1 of the application form must be signed by the following:

a. chief radiologist
b. chief radiologic/x-ray technologist
c. radiation safety officer who may be the radiologist or the radiologic/x-ray technologist
d. owner of the facility

1.

All questions in the application form must be properly answered.

2.

The duly accomplished application form must be submitted together with

a. Certificate of Training in Radiology, PRC ID & Contract of Agreement between the applicant and the
radiologist
b. Certificate of PRC registration, PRC ID & Contract of Agreement between the applicant and the radiologic/x-ray
technologist/s
c. Copy of the latest x-ray license certificate

1.

All deficiencies noted by the Bureau of Health Devices and Technology (former name: Radiation Health Service) health
physics team in the latest radiation protection survey and evaluation report must be complied with. Proof of compliance
(pictures, receipts, charts, logbooks, etc.) and a duly notarized certificate of compliance signed by an authorized
personnel of the facility must be submitted together with the application form.

2.

Correct amount of license application fee, as indicated in the attached Schedule of Fees, must be paid. Postal money order
must be made payable to the Bureau of Health Devices, Department of Health.
THANK YOU

------------------------------------------------------------------------------------------------------------------------------------------------Name of Facility : ____________________________________________________________________________________________

Address: ____________________________________________________________ License No. ___________________
______ Issuance of x-ray license
______Renewal of x-ray license
License validity period ________________________________________
No. of X-ray Machines

SCHEDULE OF FEES (Adjusted as per A.O. # 29,s.2000)

MA range of
Initial
Renewal
TOTAL FEE
100 mA and less
P 800.00
P400.00
101 mA up to 300 mA
1,100.00
550.00
301 mA up to 500 mA
1,400.00
700.00
501 mA up to 700 mA
1,700.00
850.00
Greater than 700 mA
2,000.00
1,000.00
Total
_______________
Surcharge*
_______________
Total License fee
_______________

*As per Department of Health Administrative Order No. 124s. 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 if application for renewal is filed three (3) months after expiration of license.
IMPORTANT REMINDER :
Please file your application for renewal of x-ray license two months before the
expiration to avoid payment of penalties. License application fee shall be valid only within six (6) months for non-complying applicants.
Prepared by:

Note: Please present this Schedule of Fees when paying your license fees.

_________________________________
RHS Health Physics Team

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

Fill-up completely and submit two (2) copies of this form to:
Bureau of Health Devices and Technology
Department of Health
San Lazaro Cpd., Rizal Avenue
Sta. Cruz, Manila 1003
Telefax No. 711-6016 Tel. No. 743-8301 loc. 3403-3406

If Renewal:
Previous License
Date Issued

General Information
1. Name of Institution: ___________________________________________________________________
2. Postal Address: _______________________________________________________________________
_______________________________________________________________________
Region _________________ Telephone/Fax No. _______________________________
3A. Type of X-ray Facility
3B. Type of X-ray equipment
Mobile
Radiographic
Fluoroscopic
Battery-Operated
Capacitor Discharge
Photofluorographic
Mammographic

Stationary
(pls. check)

Mobile

Stationary
Radiographic
Fluoroscopic
w/ Tomography
Computed Tomographic
Others (pls. specify)
__________________

Functioning
X-ray Unit
Below 100mA
100mA
200mA
300mA
400mA
500mA
700mA
1000mA
Above 1000mA
Total no. of units

Quantity

4A. Details of Owner

Name: ______________________________________________________________________________
Address for Correspondence : ____________________________________________________________
__________________________
Telephone No. ____________ Fax. No. ______________________
4B. Details of Owner (If Business)
Business Name: _______________________________________________________________________
Address for Correspondence : ____________________________________________________________
__________________________
Telephone No. ____________ Fax. No. ______________________

Last Renewal
For RHS Use
Date Received
Thru mail
Hand-carried
Attachments
Check
PMO
No. ___________
Amount ________
Remarks:
ok for issuance
ok for renewal
Returned
Pending

Evaluated by:
_________________
Date:
License Fee Paid:

5. Personnel Qualification:
A. Name of Chief Radiologist:____________________________________________________________
FPCR
DOH Certified
FPCCP
*Trained ______________
For *Trained, state qualifications/particulars (date & location) of training in radiology:
___________________________________________________________________________________
Signature of Chief Radiologist : ________________________________________________________
B. Name of Chief X-ray/Radiologic Technologist:_____________________________________________
Qualification: ______________________________________________PRC # ____________________
Signature of Chief X-ray/Radiologic Technologist: _________________________________________
C. Name of Radiation Safety Officer: ______________________________________________________
Qualification: _______________________________________________________________________
Signature of Radiation Safety Officer: __________________________________________________

PHP _____________
O.R. _____________
Date _____________

6. Declaration (To be Personally signed by the Owner)

Date: ____________

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.
____________________________________
Printed Name & Signature
Please state title and position held ______________________

_____________________
Date

Recommending
Approval
_________________
Date: ____________
Approved By:

Remarks:

X-ray Services
Level One includes the following non-contrast radiographic examinations
chest for heart and lung
vertebral column
extremities
localization of foreign body
skull
pelvis

shoulder girdle
thoracic cage
abdomen

Level Two includes those examinations done in level one category and the following non-contrast and contrast radiographic
examinations:
uppergastrointestinal series
intravenous pylography
fetography
small intestinal series
hysterosalpingography
pelvimetry
barium enema (large intestines series)
paranasal sinuses
myelography
esophagography (barium swallow)
skeletal survey
scoliotic series
cardiac studies with barium
imperporated anus
oral cholegraphy
Level three includes those examinations done in the level one and two categories and the following invasive procedures:
sinugraphy
tomography
all percutaneous procedure
fistulography
pacemeker implants
visceral and peripheral angiography
sialography
retrograde cystography
operative and post operative cholengiography
broncography
cerebral angiography
endoscopic retrograde cholengiographic
lympography
retrograde urography
Pancreatography
Specialized examinations done with a dedicated x-ray unit such as:
angiography
mammography
bone densitometry
computed tomography
others (pls. specify) ______________

digital substraction angiography

cardiac catheterization
percutaneous transluminal angioplasties
tumour localization and simulation

Radiation Workers
A. Radiologist/s:
1. Name: ______________________________________Date of Birth: ____________ Tel. No. _________________
Address: _________________________________________________ Date Employed: _______________________
FPCR/DPBR
DOH Certified
FPCCP
Trained

Year Inducted as PCR Fellow/Diplomate _____ (pls. attach certificate)

Year Certified as Med. Sp. in Rad. by DOH __________
Year inducted as PCCP Fellow ______ (pls. attach certificate)
Trng. Hospital ____________________________________
Duration of Training: _____________________ (pls. attach certificate of training)

2. Name: ______________________________________Date of Birth: ____________ Tel. No. _________________

Address: _________________________________________________ Date Employed: _______________________
FPCR/DPBR
DOH Certified
FPCCP
Trained

Year Inducted as PCR Fellow/Diplomate _____ (pls. attach certificate)

Year Certified as Med. Sp. in Rad. by DOH __________
Year inducted as PCCP Fellow ______ (pls. attach certificate)
Trng. Hospital ____________________________________
Duration of Training: _____________________ (pls. attach certificate of training)

B. X-ray/Radiologic Technologist:
1. Name: ______________________________________Date of Birth: _____________ Tel. No. ________________
Address: _________________________________________________ Date Employed: _______________________
X-ray Technologist
Radiologic Technologist
PRC No. ________________
PRC No. ________________
Date of Examination: ________________
Date of Registration: ________________

Date of Examination: _______________

Date of Registration: _______________

Training/s Attended: _______________________________________________________________

2. Name: ______________________________________ Date of Birth: _____________ Tel. No. ________________

Address: _________________________________________________ Date Employed: _______________________
X-ray Technologist
Radiologic Technologist
PRC No. ________________
PRC No. _______________
Date of Examination: ________________
Date of Registration: ________________

Date of Examination: _______________

Date of Registration: _______________

Training/s Attended: _______________________________________________________________

X-ray Machine Data:

A. GENERAL RADIOGRAPHY
1. Brand/Model
Serial Number
a. Tubehead _______________________
a. Tubehead ________________
b. Control Console __________________
b. Control Console __________
Maximum mA ____________________________
Maximum kVp ___________________
Type: ________________________ (please refer to page 1, item 3B of this application form)
Acquired from: __________________________
Year acquired/installed: _______________
2. Brand/Model
Serial Number
a. Tubehead _______________________
a. Tubehead ________________
b. Control Console __________________
b. Control Console __________
Maximum mA ____________________________
Maximum kVp ___________________
Type: ________________________ (please refer to page 1, item 3B of this application form)
Acquired from: __________________________
Year acquired/installed: _______________
3. Brand/Model
Serial Number
a. Tubehead _______________________
a. Tubehead ________________
b. Control Console __________________
b. Control Console __________
Maximum mA ____________________________
Maximum kVp ___________________
Type: ________________________ (please refer to page 1, item 3B of this application form)
Acquired from: __________________________
Year acquired/installed: _______________
4. Brand/Model
Serial Number
a. Tubehead _______________________
a. Tubehead ________________
b. Control Console __________________
b. Control Console __________
Maximum mA ____________________________
Maximum kVp ___________________
Type: ________________________ (please refer to page 1, item 3B of this application form)
Acquired from: __________________________
Year acquired/installed: _______________
B. COMPUTED TOMOGRAPHY
1. Brand/Model
a. Tubehead __________________________
b. Control Console ____________________
Maximum mA ______________________________
Type: (pls. specify )
Helical
Conventional
Acquired from: _____________________________
C. OTHER X-RAY EQUIPMENT (pls. specify)
1. Brand/Model
a. Tubehead __________________________
b. Control Console ____________________
Maximum mA ______________________________
Type: _____________________________________
Acquired from: _____________________________
Other specifications:

Serial Number
a. Tubehead ___________
b. Control Console ______
Maximum kVp _________________

Year acquired/installed: ___________

Serial Number
a. Tubehead ___________
b. Control Console ______
Maximum kVp _________________
Year acquired/installed: ___________