DJRMH Citizen's Charte 2022_3rd Edition FINAL

3. Availment of RT-PCR Testing

Dr. Jose Rizal Memorial Hospital COVID-19 Testing Laboratory aims to deliver real-time
quality and accurate services for the detection of COVID-19 cases. Clients for RT-PCR
must follow the step by step process wherein they shall fill-out the required forms in the
COVID-19 laboratory waiting area until the patient receives the official result sent
through electronic mail.

Availability of Service: Monday to Friday
Swabbing (6:00AM to 9:00AM)
Release of Result: (4:00PM to 6:00PM)

For POSITIVE results, Referred to their respective LGUs for isolation

Office or Division: Clinical Pathology Department - COVID-19 Testing Laboratory

Classification: Simple

Type of Transaction: Government to Citizen

Who may avail: All

CHECKLIST OF REQUIREMENTS WHERE TO SECURE

1. Case Investigation Form DJRMH COVID-19 Testing Lab

2. Laboratory Request Form DJRMH COVID-19 Testing Lab
3. Certificate of Undertaking DJRMH COVID-19 Testing Lab
4. Patient Registration Form DJRMH COVID-19 Testing Lab

Situational Requirements: DJRMH COVID-19 Testing Lab
If Client will use his/her Philhealth(PHIC):
5. Philhealth Member Registration Form

CLIENT STEPS AGENCY ACTIONS FEES PROCES PERSON
TO BE SING RESPONSIBLE
PAID TIME

1. Request for RT- 1. Acknowledges None 5 minutes Laboratory Aide II
PCR Testing and request then gives COVID-19 Testing
proceeds to patient necessary Laboratory
COVID-19 testing forms to be fill-out
laboratory waiting completely None 5 minutes Laboratory Aide II
area. COVID-19 Testing
2. Receives the Laboratory
2. Submits the required
completely fill-out documents and None 3 minutes Laboratory Aide II
forms forwards the COVID-19 Testing
patient Laboratory
3. Receives Charge registration form
slip to the OPD for
patient
registration.

3. Issues Charge Slip

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4.a Proceeds to 4.a Instructs Client on Php 20 Vicenta A. Mesiona
Cashier for minutes Administrative
payment Payment 2,800.00 Officer V
Cash Operation
*If client will avail
medical assistance 4.b Processes None 17 Social Welfare
(as applicable) availment of minutes Officer III
4.b Proceeds to MSS medical
assistance Medical Social Work
for availment of
medical 5.1 Collects swab None 5 minutes Medical
assistance samples to Technologist II
5.1 Returns to patient COVID-19 Testing
laboratory and
proceeds at the swab Laboratory
collection area for
swabbing.

5.2 Receives 5.2 Labels and None 10 hours Medical
instructions and waits transports the None Technologist II
for result via electronic samples to the COVID-19 Testing
mail Specimen
Inspection room Laboratory
6. Receives RT-PCR for acceptance
result. and processing 10 Medical
of samples and
instructs client
as necessary.

6. Releases result

minutes Technologist II

COVID-19 Testing

Laboratory

Php 2,800.00 10 hours and 48 minutes

TOTAL *if will avail medical *if will medical assistance
assistance 11 hours and 5 minutes

Depends on the discount given

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4. Availment of SARS-Cov-2 Rapid Antigen Testing

Dr. Jose Rizal Memorial Hospital COVID-19 Testing Laboratory aims to deliver real-time
quality and accurate services for the detection of COVID-19 cases. Clients for SARS-
Cov-2 Rapid Antigen Testing must follow the step by step process wherein they shall fill-
out the required forms in the COVID-19 laboratory waiting area until the patient receives
the official result.

Availability of Service: Monday to Sunday (24 hours)
Swabbing (6:00AM to 9:00AM)
Release of Result: (4:00PM to 6:00PM)

For Negative results, clients may be released. However, Close contacts with negative
results will be placed on hold and be referred to their respective LGUs for quarantine.

For POSITIVE results, clients will be placed on hold and referred to their respective
LGUs for isolation.

Office or Division: Clinical Pathology Department - COVID-19 Testing Laboratory

Classification: Simple

Type of Transaction: Government to Citizen

Who may avail: All

CHECKLIST OF REQUIREMENTS WHERE TO SECURE

1. Case Investigation Form DJRMH COVID-19 Testing Lab

2. Certificate of Undertaking DJRMH COVID-19 Testing Lab
3. Patient Registration Form DJRMH COVID-19 Testing Lab
4. RAgT Clinical and Exposure Assessment DJRMH COVID-19 Testing Lab

form

CLIENT STEPS AGENCY ACTIONS FEES PROCES PERSON
TO BE SING RESPONSIBLE
1. Proceeds to 1. Acknowledges PAID TIME
COVID-19 testing request then gives None 10 Laboratory Aide II
laboratory waiting patient necessary COVID-19 Testing
area and Request forms to be fill-out minutes
for SARS-Cov-2 completely Laboratory
Rapid Antigen
Testing

2. Submits the 2. Receives the None 5 minutes Laboratory Aide II
completely fill-out required COVID-19 Testing
forms documents. Laboratory

3. Receives Charge 3. Issues Charge Slip None 3 minutes Laboratory Aide II
slip COVID-19 Testing
Laboratory

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4.a Proceeds to 4.a Instructs Client on Php 20 Administrative
Cashier for minutes Officer V
payment Payment 660.00
CASH Operation

*If client will avail 4.b Processes None 17 Social Welfare
medical assistance availment of minutes Officer III
(as applicable) medical
4.b Proceeds to MSS assistance Medical Social Work

for availment of
medical
assistance

5.1 Returns to 6.1 Collects swab None 5 minutes Medical
laboratory and samples to Technologist II
proceeds at the swab patient COVID-19 Testing
collection area for
swabbing. Laboratory

5.2 Awaits results in 6.2 Forwards the None 30 Medical
the OPD holding Area minutes Technologist II
swab samples COVID-19 Testing

in the laboratory Laboratory

for processing

and gives

printed official

result.

Php 660.00 1 hour and 13 minutes

TOTAL *if will avail medical *if will medical assistance
assistance 1 hour and 30 minutes

Depends on the
discount given

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CLINICAL PATHOLOGY DEPARTMENT

Internal Service

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1. Availment of Laboratory Services for In-Patients

Clinical Pathology Department services are sought to assist the clinical management of
patients. Various procedures within the scope of its license as a secondary laboratory
can be availed by In-Patients.

ROUTINE TESTS INCLUDES: Routine Blood SPECIAL TESTS
 Complete Blood Count (with Platelet) Chemistry INCLUDE:
 Gram Staining
 Urinalysis  FBS/RBS  KOH
 HIV Testing
 Fecalysis/ Stool Exam  BUN  HbsAg
 Blood Typing  Creatinine

 Lipid Profile

 BUA

 SGPT

 SGOT

Availability of Service: Monday to Sunday (24 hours)

Office or Division: Clinical Pathology Department

Classification: Simple

Type of Transaction: G2G-Government to Government

Who may avail: Nurse on Duty, Nursing Attendant

CHECKLIST OF REQUIREMENTS WHERE TO SECURE

Completely Filled up Laboratory Request form WARD / ER

(1 original copy)

CLIENT STEPS AGENCY ACTIONS FEES PROCESS PERSON
TO BE ING TIME RESPONSIBLE
1. Inputs laboratory 1.1 Reviews iHOMIS/ PAID
request/s to Patient’s None 5 minutes Laboratory Aide III
patient’s account Laboratory Clinical Pathology
through iHOMIS Examination
Monitoring Department
System and
accepts the
request/s

1.2 Proceeds to area None 15 minutes Medical
where patient is Technologist III
admitted Clinical Pathology

Department

1.3 Extracts/ Collects None 15 minutes Medical
blood Technologist III
Clinical Pathology

Department

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2. Waits for test result 2. Goes back to the None STAT Medical
to be forwarded laboratory and Within 1 Technologist III
processes sample hour upon Clinical Pathology
for examination receiving
and clicks the samples Department
appropriate icons
in the iHOMIS to Routine
reflect charges in Tests
patient’s hospital 2 hours
bill. upon

receiving
the samples

Blood
Chemistry:

5 hours
upon

receiving
the samples

3. Receives 3. Inputs lab results None 35 minutes Medical
laboratory result thru electronically Technologist III
thru electronically or provides lab Clinical Pathology
or receives lab results to the
results from the corresponding Department
laboratory staff ward

STAT

2 hours and 10 minutes

TOTAL None Routine Tests

6 hours and 10 minutes

Blood Chemistry

3 hours and 10 minutes

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MEDICAL SOCIAL WORK

External Services

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1. Availment of Medical Assistance

This service involves processing medical assistance to the financially incapacitated
client to be able to access needed health services or interventions until the time client
receives the necessary assistance/support and services.

Availability of Service: Monday to Sunday ( 24 Hours )

Office or Division: Medical Social Work

Classification: Simple

Type of Transaction: G2C – Government to Citizen

Who may avail: All Patients

CHECKLIST OF REQUIREMENTS WHERE TO SECURE

1. Any of listed requirements as

applicable

 Charge Slip (1 original copy) Radiology/Clinical Pathology/CSR/ER

 Statement of Account (4 original copy) Billing & Claims
 Order of Payment Slip (1 original copy) Pharmacy
 Medical Certificate/ Medical Abstract Health Information Management Office

(1 original/certified true copy)

2. Medical Social Work Service Card Medical Social Work (MSW) Section
(1 original copy)

3. Any of listed requirements, as

applicable

 Certificate of Indigency (1 original copy) - Barangay/DSWD

 4P’s ID (1 photocopy) - DSWD
 MDR/PBEF (1 photocopy) - PHIC
 Senior Citizen ID (1 photocopy) - Office of Senior Citizen’s Affairs
 PWD ID (1 photocopy) - City/Municipal Social Welfare and

Development Office

 BHW ID or original certification as BHW - Rural Health Unit / DOH Regional Office

 (1 photocopy)

 ID as elected barangay official or - DILG
photocopy of Oath of Office as elected

Barangay Official in the latest election

(1 photocopy)

FEES

CLIENT STEPS AGENCY ACTIONS TO PROCESSING PERSON

BE TIME RESPONSIBLE

PAID

1. Presents charge 1.Updates patient’s None 10 minutes Social Welfare

slip/SOA/Order of record & receives Officer III
Payment Slip & any documentary Medical Social
Medical Social requirements (as
Work

Service Card and applicable) then

any documentary checks charge

requirements, as slip/Order of

applicable. Payment

Slip/statement of

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account and
determines amount
for medical
assistance to be
provided to client,
or possible cost
sharing.

2. Acknowledges 2.Indicates amount None 8 minutes Social Welfare
Medical assisted and/or Officer III
Assistance availed amount to be paid
or signs logbook of and stamps in the Medical Social
Quantified Free charge slips/Order Work
Services(QFS) of payment slip or
SOA.

For OPD clients with 3.a Instructs client to None 3 minutes Social Welfare
counterpart proceed to the Officer III
payment: Cashier for payment None
3.a Proceeds to before proceeding to None Medical Social
cashier for payment the cost centers for None Work
before going to the the services needed.
cost centers for the 3 minutes Social Welfare
services needed. 3.b Instructs client to Officer III
proceed to the cost
For OPD clients center to avail the Medical Social
without counterpart services needed. Work
or Full MAIP
assistance:
3.b Proceeds to the
cost centers for the
services needed.

For ER and In 3.c Instructs client to 3 minutes Social Welfare
patients: proceed to the Officer III
3.c Proceeds to the cashier for payment
cashier for payment and/or clearance that Medical Social
and/or clearance. is needed to be Work
presented to the
ward nurse or ER
nurse for their final
discharge.

TOTAL 21 minutes

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2. Availment of Medico-Legal Examination at the Women and Child
Protection Unit

WCPU Is a unit that serves a holding and processing area to victims/survivors of
violence against women and their children (VAWC). It is a composed of multidisciplinary
team members that provides comprehensive medical and psychosocial services to
women and children survivors of violence. This service involves processing medico-
legal examination from the time the client is referred and/or submits for medical
examination until the time client receives advice to claim the Medico-legal certificate.

Availability of Service: Monday to Sunday ( 24 Hours )

Office or Division: Medical Social Work – Women and Children Protection Unit

Classification: Simple

Type of Transaction: G2C – Government to Citizen

Who may avail: Victims/survivors of VAWC

CHECKLIST OF REQUIREMENTS WHERE TO SECURE

Referral letter or Police request Government agencies such as but not

(1 original copy) limited to DSWD, PNP, NBI, etc. or

NGOs/Pos. , Philippine National Police

Note: Walk in clients need not present

requirements.

FEES

CLIENT STEPS AGENCY ACTIONS TO PROCESSING PERSON
BE TIME RESPONSIBLE

PAID

1. Presents referral 1. Assesses referral None 15 minutes Nurse II
Emergency Room
letter/police letter as to what

request, if kind of service/s

available. is/are requested or

needed

2. Accomplishes 2.1 Verifies personal None 15 minutes Nurse II
Patient Data information Emergency Room

Information at the submitted and

ER Triage for prints patients’

registration record.

2.2 Informs physician

and forwards

patient to WCPU.

3.1 Gives consent/ 3.1 Secures informed None 10 minutes Nurse II
assent for medical consent, assent Emergency Room

examination. and/or other

applicable

consent for

interview and

examination.

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3.2 Submits for 3.2 Conducts intake None 1 hour Social Welfare
interview and interview Officer III
examination assessment.
Medical Social Work

3.3 Submits for 3.3 Conducts medical None 45 minutes Attending Physician
Medical examination, Emergency Room
Examination, takes appropriate *(Cost 10 hours
evidence documentation vary 5 minutes Nurse II
gathering and and orders depen 2 hours Emergency Room
documentation necessary tests, ding
procedures and/or on the Attending Physician
4. Proceeds to cost prescribe test / Emergency Room
centers for the medicine, proced Attending Physician
performance of including referral ures or Emergency Room
test/procedure or to other agency or medici
get prescribed sections, as nes)
medicines, as necessary.
ordered by
physician. 4. Carries out
request, facilitates
performance of
necessary tests/
procedure or
medicines.

5. Returns to WCPU 5.1 Explains None
for planning & disposition and None
counseling, and give further
waits for further instructions.
instruction.
5.2 Makes medico-
legal certificate.

6. Receives advice 5.3 Initiates plan of None 30 minutes Social Welfare
where to proceed action and None 10 minutes Officer III
provides
to counseling. Medical Social Work
claim Medico-legal
Certificate. 6.1 Advices patient/ Social Welfare
accompanying Officer III
adult to proceed
to HIM/Medical Medical Social Work
Record to claim

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the Medico-legal
Certificate.

6.2 Endorses patient None 10 minutes Social Welfare
health record to Officer III
HIM.
Medical Social Work

TOTAL *(Cost vary depending on the 15 hours and 20 minutes
test/procedures or medicines)

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3. Availment of MSS Classification/Re-Classification of Patient

This service involves accessing medical social work services through the classification
system from the time the client submits for interview and assessment until the time client
receives the his/her appropriate assessment/classification. This covers all patients who
either seek consultation (OPS & ER) or admission in the hospital. On the basis of their
economic status or paying capacity and poverty threshold level. There are three social
classifications namely; full pay, partial pay and the poor and indigent.

Availability of Service: Monday to Sunday ( 24 Hours )

Office or Division: Medical Social Work

Classification: Simple

Type of Transaction: G2C – Government to Citizen

Who may avail: Walk in or Referred Patients (In- Patients, ER clients, OPD)

CHECKLIST OF REQUIREMENTS WHERE TO SECURE

Medical Social Work Card (1 original copy) Medical Social Work (MSW) Section

CLIENT STEPS AGENCY FEES TO PROCESS PERSON
ACTIONS BE PAID ING TIME RESPONSIBLE

For NEW Clients: 1.a Interviews and None 20 minutes Social Welfare Officer III
1.a Fills out necessary assesses Medical Social Work
client’s socio- None
information and economic None 10 minutes Social Welfare Officer III
submits for status or the Medical Social Work
interview and financial
assessment . and capability and 5 minutes Social Welfare Officer III
presents ID as coping Medical Social Work
necessary for capacity of the
identification client.
purposes
1.bReceives
For OLD Clients: Medical Social
1.b Presents Medical Work Service
Card and
Social Work updates
Service Card record

2. Receives 2. Provides
assessment and assessment,
Medical Social issues Medical
Service Card. Social Work
Service Card
for new
clients, re-
issue or
revalidates
Medical Social
Service Card
for old clients

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3. Asks information 3. Provides None 10 minutes Social Welfare Officer III
relative to information on None Medical Social Work
hospitalization/ the scope of
consultation services and New Client : 45 minutes
issues/ concerns limitations and Old Client : 25 minutes
and or difficulty. explains
necessary
requirements
and provides
necessary
intervention to
client’s
presenting
problem.

TOTAL

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4. Availment of Philhealth Enrolment through Point Of Service (POS)

Point of Service (POS) refers to the program to cover all Filipinos (the unregistered and
inactive members) under the National Health Insurance Program, through the General
Appropriations Act for the current year. This service involves processing of Philhealth
enrolment from the time client seeks information for compliance of requirements up to
the time client is successfully enrolled at the system and tagged as PHIC Hospital
Sponsored Member.

Availability of Service: Monday to Sunday ( 24 Hours )

Office or Division: Medical Social Work

Classification: Simple

Type of Transaction: G2C – Government to Citizen

Who may avail: Admitted clients/patients

CHECKLIST OF REQUIREMENTS WHERE TO SECURE

1. Any of listed documentary requirements

(as applicable):

 Birth Certificate (1 Photocopy) Philippine Statistics Authority (PSA)
 Affidavit of guardianship of the legal Public Attorney’s Office

guardian in the absence of their parents

(1 original copy)

2. Duly accomplished PMRF (1 original copy) Medical Social Work (MSW) Section

For Financially Capable: PHIC-LHIO – Dipolog City
3. Official Receipt (OR) (1 original copy)

CLIENT STEPS AGENCY FEES PROCESS PERSON
ACTIONS TO BE ING TIME RESPONSIBLE
1. Presents PAID
documentary 1. Receives &
requirements checks None 10 minutes Social Welfare Officer III
documentary
requirements Medical Social Work
and provides
needed
information

2.1 Waits to be 2.2 Enrolls patient None 1 hour Social Welfare Officer III
enrolled at to Philhealth Medical Social Work
Philhealth POS POS System,
System and issues note
as proof of
PHIC enrolment

For Financially 2.2.a Instructs None Social Welfare Officer III
Incapable: watcher/ 5 minutes Medical Social Work
patient to
2.2.a Proceeds to the submit
Billing and
Claims to submit
documents.

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For Financially documents to None 1 day Social Welfare Officer III
Capable: Billing & Medical Social Work
Claims for
2.2.b.1 Proceeds to proper
Philhealth Local tagging.
Health Insurance
Office, Dipolog 2.2.b.1 Instructs
City to pay the client to pay
Annual PHIC Annual
Premium then Premium at
returns to the PHIC-
LHIO,
Dipolog City
for PHIC
membership
and instructs
patient to
return to
hospital.

2.2.b.2 Returns to 2.2.b.2 Encodes None 3 minutes Social Welfare Officer III
hospital and OR at the Medical Social Work
submits OR from POS System
PHIC-LHIO and

2.2.b.3 Waits for the 2.2.b.3 Generates None 30 minutes Social Welfare Officer III
release of POS POS Medical Social Work
registration slip registration
then proceeds to slip and
Billing and instructs
Claims. client to
proceed to
Billing &
Claims.

TOTAL None Financially Incapable:
1 hour and 15 minutes

Financially Capable:
1 day, 1 hour and 43 minutes

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5. Availment of Services at Malasakit Center (Verification of PHIC Status
& Medical/Financial Assistance)

Malasakit Center serves as a one-stop shop, where the different participating agencies
receive and process request for medical and financial assistance for indigent and
financially incapacitated patients. This service involves verification of PHIC status,
processing of medical/financial assistance and navigating other services from the time
the client presents complete documents up to the time appropriate services are being
rendered.

Availability of Service: Mondays to Fridays, except Holidays
(8:00-12:00 AM and 1:00-5:00 PM)

Office or Division: Medical Social Work - Malasakit Center

Classification: Simple

Type of Transaction: G2C – Government to Citizen

Who may avail: All patients

CHECKLIST OF REQUIREMENTS WHERE TO SECURE

A. FOR MEDICAL ASSISTANCE: DOH-

MSW

1. Any of listed requirements as

applicable ( as proof of the needed

medical services)

 Charge Slip (1 original copy) - Radiology/Laboratory/CSR/ER
 Statement of Account (1 original copy) - Billing & Claims
 Order of Payment Slip (1 original copy) - Pharmacy

2. Medical Social Work Service Card Medical Social Work (MSW)
(1 original copy)

3. Any of listed requirements, as

applicable ( as proof of

indigency/underprivileged sector)

 Certificate of Indigency (1 original copy) - Barangay/DSWD

 4P’s ID (1 photocopy) - DSWD

 Sponsored MDR/PBEF (1 original copy) - PHIC/Billing & Claims

 Senior Citizen ID (1 original copy) - Office of Senior Citizen’s Affairs
 PWD ID (1 original copy) - City/Municipal Social Welfare and

Development Office

 BHW ID (1 original copy) - Rural Health Unit / DOH Regional Office
 Barangay Official ID (1 original copy) - DILG

FOR FINANCIAL (BURIAL,

TRANSPORTATION, ETC.) ASSISTANCE:

DSWD

1. 1 original copy of Certificate of Indigency Barangay

2. 1 original copy/certified true copy of HIMS Window 1

Medical Certificate/Medical Abstract

3. Proof of needed assistance such as, Hospital/CHO or MHO

death certificate, request of

test/procedure, etc.

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4. 1 copy of Social case summary Municipality Social Welfare Office or medical
report/social case study social worker

FOR PHIC STATUS PHIC LHIO
INQUIRY/PROBLEMS, PHIC DATA PSA, Local Civil Registar
UPDATING, ETC.
1. Any of the following:
- PHIC ID with PIN or MDR
- Birth Certificate or correct data of member
esp. name & birthdate

CLIENT STEPS AGENCY FEES PROCESS PERSON
ACTIONS TO BE ING TIME RESPONSIBLE
PAID
1. Presents 1. Provides None 5 minutes Social Welfare Officer III
documentary information of Medical Social Work -
requirements for services and
the services requirements Malasakit Center
needed and endorses
client to the None 5 minutes Social Welfare Officer III
2. Accomplishes partner agency Medical Social Work -
necessary forms by providing
and waits for the priority number. Malasakit Center
number to be
called 2. Advises client to None 5 minutes Social Welfare Officer III
proceed to the Medical Social Work -
3. Proceeds to the waiting area
designated counter and waits for Malasakit Center
of the partner the number to
agency when be called and/or None 15 minutes Social Welfare Officer III
called and displayed on Medical Social Work -
presents queuing the screen.
number. Malasakit Center
3. Receives
4. Provides accurate queuing None 5 minutes Social Welfare Officer III
and complete number. Medical Social Work -
information as Receives
needed, and signs review and Malasakit Center
necessary validates
documents documents
presented.
5. Proceeds to the
cashier for 4. Interviews
payment, if client, assesses
applicable, or to needs and
the appropriate provides
necessary
assistance.

5. Advises client
where to
proceed.

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service centers None 35 minutes
they needed as
advised by the
partner agency or
social worker.

TOTAL

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NUTRITION AND DIETETICS

External Service

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1. Availment of Nutritional and Dietetics Service

The Nutrition and Dietetics Section is responsible in the provision of optimal nutrition
care through quality food service. This service starts from the time client is referred to
dietary until the time client receives dietary instruction regarding prescribed diet.

Availability of Service: Monday to Friday; 8:00 am to 5:00 pm

Office or Division: Nutrition and Dietetics Service (NDS)

Classification: Simple

Type of Transaction: G2C – Government to Citizen

Who may avail: Out-Patient Clients

CHECKLIST OF REQUIREMENTS WHERE TO SECURE

1. Intra-Agency Referral Sheet OPD

(1 original copy)

2. Laboratory Result/s (1 original copy) OPD

3. Prescription Form (1 original copy ) OPD

FEES

CLIENT STEPS AGENCY TO PROCESSING PERSON
ACTIONS BE TIME RESPONSIBLE

PAID

1. Presents required 1. Receives None 5 minutes Nutritionist Dietitian III
documents required Nutrition and Dietetics
documents
Section

2. Receives dietary 2. Prepares None 30 minutes Nutritionist Dietitian III
instruction necessary Nutrition and Dietetics
instructional
Section

materials and

provides

dietary

instruction

regarding

prescribed diet

TOTAL None 35 minutes

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PHARMACY

External Service

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1. Dispensing of Drugs and Medicines

This service involves dispensing of drugs and medicines to hospital clients including out-
patients from the time the client presents prescription until the time the client receives
the drugs and medicines.

Availability of Service: Monday to Sunday (24 hours)

Office or Division: Pharmacy

Classification: Simple

Type of Transaction: G2C – Government to Citizen

Who may avail: Outpatient / Walk-In

CHECKLIST OF REQUIREMENTS WHERE TO SECURE

1. Prescription (1 original copy) Emergency Room/Outpatient Department/

Requesting Physician

2. Order of Payment (1 original copy) Pharmacy

3. Official Receipt (1 original copy) Cash Operations Section

CLIENT STEPS AGENCY ACTIONS FEES PROCESSING PERSON
TO BE TIME RESPONSIBLE
PAID

1. Presents Prescription 1. Checks the None 3 minutes Pharmacist III
Pharmacy
and receives completeness

instructions and correctness

of the

prescription and

the medicines.

1.1 Receives unfilled For unfilled None 2 minutes Pharmacist III
prescription prescription, 17 minutes Pharmacy
1.1 Returns None 20 minutes
2.a Receives order of Social Welfare
payment and prescription if *pleas Officer III
proceeds to cashier non-available e refer
for payment 2.a Issues order of Medical Social
payment and to Work
*If patient will avail for directs to cashier table
medical assistance for payment of Administrative
2.b Proceeds to MSW charges Officer V

for availment of 2.b Processes Cash Operations
medical assistance availment of Section
If with excess: medical
Proceeds to cashier assistance
(Step 3)
If no excess: *MSW on duty will
Proceeds to Step 4: stamped “MSW”
3. Presents order of on the charge
payment and pays slip
corresponding
amount 3. Issues official
receipt

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4.1 Presents Official *Cashier on duty will below 2 minutes Pharmacist III
Receipt / MSS stamped “Paid” with for Pharmacy
Stamped Order of OR Number on the
Payment charge slip applica
ble
4.1 Receives Official fees
Receipt / MSS None
Stamped Order
of Payment

4.2 Checks dispensed 4.2 Dispenses None 3 minutes Pharmacist III
medicine and medicine/s and Pharmacy
receives gives *please
instruction/s if any instruction/s if refer to
any
table
TOTAL below for 30 minutes
applicabl
*If patient will avail for medical
e fees assistance
= 47 minutes
*Depends
on the
discount
given

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PHARMACY
LIST OF AVAILABLE DRUGS AND MEDICINES
AS OF MARCH 22, 2022

DRUGS AND MEDICINES DESCRIPTION RETAIL PRICE

ACETAZOLAMIDE (CETAMID) 250MG TABLET 28.00
ACETYLCYSTEINE 600MG TABLET 21.00
ACICLOVIR (ZEALOR) 400 MG TABLET 15.25
ACICLOVIR 400 MG TABLET 29.75
ACICLOVIR (XYCLOVIRAX FORTE) 800 MG TABLET 63.00
ACICLOVIR 800MG TABLET 64.00
ADENOSINE (CARDIOSINE) 3 MG/ML, 2 ML AMPULE 290.00
ALL-IN-ONE ADMIXTURES 1,400 KCAL 2,975.00
ALLOPURINOL (URISOL) 100MG TABLET
ALLOPURINOL 300MG TABLET 2.00
ALUMINUM + MAGNESIUM 4.50
HYDROXIDE (SHELOGEL) 200MG + 100MG TABLET
AMIKACIN 2.50
AMIKACIN (COCINE) 100MG/2ML VIAL
AMIKACIN (COCINE) 250MG/2ML VIAL 89.50
(COCINE) 500MG/2ML VIAL 83.00
AMINO ACID + SORBITOL (AMINODEN) 500 ML BOTTLE SOLUTION FOR IV 135.00
INFUSION
AMINO ACID + SORBITOL 500 ML BOTTLE SOLUTION FOR IV INFUSION 831.00
AMINOPHYLLINE 25MG/ML, 10ML
AMIODARONE (RHTYMA) 150MG/ML, 3ML 615.00
AMLODIPINE (AMDIPINE) 10MG TABLET 55.00
AMOXICILLIN (AMBIMOX) 500 MG CAPSULE
AMOXICILLIN (AXMEL) 250MG/5ML, 60ML SUSPENSION 951.00
AMPICILLIN (LIFERZIN) 250 MG VIAL 0.70
AMPICILLIN (AMBILIN) 500MG VIAL 5.50
AMPICILLIN + SULBACTAM (SULBACIN) 750 MG POWDER FOR INJECTION
AMPILCILLIN + SULBACTAM (SULBACIN) 1 G / 500 MG POWDER FOR INJECTION 75.00
52.75
ANTI-TETANUS SERUM (ANTITET) 1,500 IU AMPULE 39.00
29.25
ARIPIPRAZOLE (ABILIFY DISCMELT) 15MG TABLET 65.50
95.50
ASCORBIC ACID (MYREVIT-C) 500MG TABLET 255.00

ASCORBIC ACID (APCEE) 100MG/5ML, 60ML SYRUP 1.25
ATORVASTATIN (STALIP) 80MG TABLET 67.00
ATRACURIUM (ACURIUM) 10MG/ML, 2.5ML 18.75
AZITHROMYCIN (TROZIN) 500 MG TABLET 114.75
AZITHROMYCIN (AZICARE) 500MG TABLET 15.00
AZITHROMYCIN (TROZIN) 500 MG TABLET 15.00
AZITHROMYCIN (AZTROZIN) 500 MG VIAL 13.75
AZITHROMYCIN (AZTROZIN) 500 MG VIAL 367.00
AZITHROMYCIN (ZITHROCARE) 200 mg/5 ml, 15 ml BOTTLE 289.00
BARICITINIB (BARICITINIB) 4MG TABLET 255.00
495.00

125 | P a g e

DRUGS AND MEDICINES DESCRIPTION RETAIL PRICE
BETAHISTINE (VERIST-8) 8 MG TABLET 19.50
BETAHISTINE (BETZINE) 16 MG TABLET 14.50
BETAHISTINE (BETZINE) 24 MG TABLET 63.00
BIPERIDEN (AKETON) 2 MG TABLET 6.50
BIPHASIC ISOPHANE
HUMAN INSULIN 70/30 (INSUGET) 100 IU/ML, 10ML VIAL 375.00
BISACODYL
BISACODYL (PRELAX) 5MG TABLET 2.00
BUDESONIDE (DULXATIVE) 10MG SUPP 26.25
BUTORPHANOL (BUDEXA) 250MCG/ML, 2ML 67.75
CALCIUM GLUCONATE (ZINOL) 2MG/ML, 1ML AMPULE 525.00
CEFALEXIN (CALCILYTE) 10%, 10 ML AMPULE 22.25
CEFAZOLIN (EXEL) 500 MG CAPSULE
CEFIXIME (HAZOLIN) 1G VIAL 7.50
(ZEFIX) 200MG 25.00
CEFIXIME (ACECEF) 100 MG/5 ML, 60 ML POWDER FOR 11.00
SUSPENSION
CEFOTAXIME (CEFOTAX) 500MG VIAL 171.00
CEFOXITIN (HOXIT) 1 G VIAL
CEFUROXIME (AXEFIME) 500 MG TABLET 315.00
CEFUROXIME (AXEFIME) 500 MG TABLET 104.75
CEFUROXIME (ZICEF) 750 MG VIAL
CEFUROXIME (EXECORE) 1.5G VIAL 12.25
CEFTAZIDIME (ZEFTACARE) 1 G VIAL 13.00
CEFTAZIDIME (ZEFTACARE) 1 G VIAL 26.25
CELECOXIB (SAPHLECOX) 200MG TABLET 68.50
CEFTRIAXONE (SITIXON) 1G VIAL 45.25
CHLORAMPHENICOL 53.00
SODIUM (KLORFEN) 1 G VIAL
CHLORPOMAZINE 4.50
CHLORPOMAZINE (GLOBAZINE) 100MG TABLET 135.00
CINNARIZINE (GLOBAZINE) 200MG TABLET
CIPROFLOXACIN (GORIZINE) 25 MG TABLET 38.25
CIPROFLOXACIN (PROVEX) 500MG TABLET
CLARITHROMYCIN (ACIPRO) 2 MG/ML, 100ML VIAL 3.75
CLINDAMYCIN (CLARYL) 500 MG TABLET 4.25
CLONIDINE (DALACIN) 150 MG/ML, 4 ML AMPULE 1.75
CLONIDINE (CLODIN) 75MCG TABLET 1.75
CLOPIDOGREL (CATAPIN) 150MCG/ML AMPULE 96.00
CLOXACILLIN (ARTHEOGREL) 75 MG TABLET (60'S ONLY) 18.25
CLOZAPINE (CLOXANE) 500MG CAPSULE 92.25
CO-AMOXICLAV (CLOPIXENE) 100MG TABLET 8.50
COLCHICINE (KLAVIC) 625MG TABLET 125.00
CONJUGATED EQUINE (GOUTSAPH) 500MCG TABLET 1.50
ESTROGEN 4.50
DEXAMETHASONE (CONGEST-0.625) 655 MCG TABLET 9.75
DEXTROSE 10.00
(DEXAMAK) 4MG/ML, 2ML AMPULE 3.75
50%, 50ML
16.75

159.00
58.75

126 | P a g e

DRUGS AND MEDICINES DESCRIPTION RETAIL PRICE
5MG/ML, 2ML AMPULE 112.50
DIAZEPAM (CARDIOXIN) 250MCG/ML, 2ML AMPULE 142.00
(HISTAZYN) 500MG CAPSULE 1.50
DIGOXIN (HISTAZYN) 12.5MG/5ML, 60ML SYRUP 29.75
DIPHENHYDRAMINE (BEXIL) 50MG/ML, 1ML AMPULE 30.50
DIPHENHYDRAMINE (DOBUMIN) 50 MG/ML, 5 ML AMPULE 237.00
DIPHENHYDRAMINE (TORIDON) 10MG TABLET 2.00
(ZYPEZIL) 10MG TABLET 39.00
DOBUTAMINE (MYDOXY) 100 MG TABLET 3.50
50MG/ML, 1ML AMPULE (IN-PATIENT ONLY) 237.00
DOMPERIDONE (MYELAX) 50MG TABLET 15.25

DONEPEZIL ( VINRAB) 200IU/5ML VIAL 1,490.00

DOXYCYCLINE (ERYSAPH) 500MG TABLET 8.50

EPHEDRINE (ERYZIN) 0.5%, 3.5 G TUBE 155.50

EPERISONE (FINFLOW) 5MG TABLET 9.75
EQUINE RABIES (FLUANXOL) 20 MG/ML, 1 ML AMPULE 391.75
IMMUNOGLOBULIN (PRODIN) 20MG CAPSULE
ERYTHROMYCIN 29.00
ERYTHROMYCIN EYE (FORAIR) 125MCG/25MCG
OINTMENT 278.75
FINASTERIDE (FORAIR) 250MCG/25MCG
386.75
FLUPENTIXOL (POLIK) 5MG TABLET
(UROMID) 40MG TABLET 5.25
FLUOXETINE (ROSEMIDE) 10 MG.ML, 2 ML AMPULE 3.00
FLUTICASONE + (MAXIGEN) 40MG/ML, 2MLAMPULE 6.75
SALMETEROL (ZELTINE) 60MG MR TABLET (30'S ONLY) 6.00
FLUTICASONE + (ZEBET) 80MG TABLET 9.50
SALMETEROL (PERIDOL) 5MG TABLET 3.75
FOLIC ACID (SEREDOL) 5MG/ML, 1ML AMPULE 4.25
492.50
FUROSEMIDE 0.5ML VIAL
1,985.00
FUROSEMIDE 20%, 50ML VIAL (ALBUMAX)
(ZACZIN) 20MG/ML, 1ML AMPULE 3,525.00
GENTAMICIN 500 ML BAG 231.00
(HYDOC) 500 MG CAPSULE 615.00
GLICLAZIDE (HYOSAPH) 10 MG FILM-COATED TABLET 19.50
(SPASBASCINE) 20MG/ML, 1ML 12.00
GLICLAZIDE 250ML 90.75
(SQFEN) 200MG/5ML, 60ML BOTTLE 971.75
HALOPERIDOL 118.75
50MG/ML, 50ML VIAL
HALOPERIDOL 8,365.00
HEPATITIS B 50MG/ML, 100ML VIAL
IMMUNOGLOBULIN 15,840.00
HUMAN ALBUMIN (VISIPAQUE) 652 MG/ML (325 MG IODINE), 50 ML VIAL
(OMNIHEXOL) 300 MG/ML, 50 ML VIAL (NO TO OUT) 2,768.75
HYDRALAZINE 500 MCG/2.5 MG, 2 ML NEBULE (FREE) 1,314.00

HYDROXYETHYL STARCH 32.00

HYDROXYUREA

HYOSCINE

HYOSCINE

HYPERTONIC LACTATE

IBUPROFEN
IMMUNOGLOBULIN NORMAL
(HUMAN)
IMMUNOGLOBULIN NORMAL
(HUMAN)
IODIXANOL
IOHEXOL
IPRATROPIUM +
SALBUTAMOL

127 | P a g e

DRUGS AND MEDICINES DESCRIPTION RETAIL PRICE
IRBESARTAN 300 MG TABLET 23.00
ISOSORBIDE DINITRATE (ISOKET) 1 MG/ML, 10 ML AMPULE
30MG TABLET 196.50
ISOSORBIDE MONONIRATE (VASTROTE) 60MG TABLET 13.75
(FERON) 20 MG/ML, 5 ML AMPULE (REPLACEMENT) 9.50
ISOSORBIDE MONONIRATE
(D5 0.3 NaCl) 500 ML BOTTLE 182.00
IRON SUCROSE 40.75
(D5 0.9 NaCL) 1 LITER BOTTLE
I.V.FLUIDS 5% DEXTROSE IN 55.00
0.3% SODIUM CHLORIDE (D5 WATER) 250ML BOTTLE (PLASTIC)
67.50
I.V. FLUIDS 5% DEXTROSE (D5 WATER) 250ML BOTTLE (GLASS)
IN 0.9% SODIUM CHLORIDE 89.50
I.V. FLUIDS 5% DEXTROSE (D5 WATER) 500ML BOTTLE
IN WATER 41.00
I.V. FLUIDS 5% DEXTROSE (D10 WATER) 500ML BOTTLE
IN WATER 44.75
I.V. FLUIDS 5% DEXTROSE (D5 IMB) 1L BOTTLE
IN WATER 68.25
I.V. FLUIDS 10% DEXTROSE (D5 IMB) 500 ML BOTTLE
IN WATER 34.00
I.V. FLUIDS BALANCE (D5 LR) 1 LITER BOTTLE
MULTIPLE MAINTENACE 102.50
SOLUTION WITH 5% (D5 LR) 500 ML BOTTLE
DEXTROSE 81.00
I.V. FLUIDS BALANCE (PNSS) 50ML BOTTLE
MULTIPLE MAINTENACE 26.25
SOLUTION WITH 5% (PNSS) 1 LITER BOTTLE
DEXTROSE 102.50
I.V FLUIDS LACTATED (PNSS) 1 LITER BOTTLE FOR IRRIGATION
RINGER'S SOLUTION 45.25
I.V FLUIDS LACTATED (PLR) 1 LITER BOTTLE
RINGER'S SOLUTION (ETAMINE) 50MG/ML, 1ML VIAL 38.25
I.V FLUIDS SODIUM (KETRAL) 30MG/ML, 1ML AMPULE 672.75
CHLORIDE (B-LACT) 3.35G/5ML, 120ML SYRUP
I.V FLUIDS SODIUM (LEVIPIL) 500MG TABLET 19.45
CHLORIDE (LEVIPIL) 500MG TABLET 375.00
I.V FLUIDS SODIUM (KEPPRA) 500MG/5ML VIAL
CHLORIDE (CARBIDEL) 100MG + 25MG TABLET 12.75
I.V FLUIDS LACTATED (LQUIN) 500MG CAPSULE 14.00
RINGER'S SOLUTION (LEVOXIN) 5MG/ML, 100ML VIAL 1,414.50
(LAXIN) 5MG/ML, 100ML VIAL 19.25
KETAMINE 50MCG TABLET (NO TO OUT)
20MG/ML (2%), 1.8ML CARPULE 5.50
KETOROLAC (XYCLOCAINE) 10% SPRAY, 50ML 158.50
(LOCAINE) 20MG/ML (2%), 50ML VIAL 795.00
LACTULOSE (LOSART) 50MG TABLET ( by 60's only)
(250 MG/ML, 20 ML VIAL 4.55
LEVETIRACETAM (RENIMAX) 20%, 500 ML BOTTLE 33.50
LEVETIRACETAM 500 MG TABLET 2,281.00
LEVETIRACETAM 135.00
LEVODOPA + CARBIDOPA
LEVOFLOXACIN 1.10
LEVOFLOXACIN 33.25
90.50
LEVOFLOXACIN
8.25
LEVOTHYROXINE

LIDOCAINE + EPINEPHRINE

LIDOCAINE

LIDOCAINE

LOSARTAN

MAGNESIUM SULFATE

MANNITOL

MEBENDAZOLE

128 | P a g e

DRUGS AND MEDICINES DESCRIPTION RETAIL PRICE
(INFAMIX) 500MG TABLET 2.50
MEFENAMIC ACID (MEMANDIN) 10MG TABLET
MEMANTINE (DOPAMAINE) 250MG TABLET 22.75
METHYLDOPA 5MG/ML, 2ML 11.75
METOCLOPRAMIDE (MEDIZOLE) 500MG TABLET 12.50
METRONIDAZOLE (ULTERGIN) 200MCG/ML, 1ML
METHYLERGOMETRINE (METROZOLE) 125MG/5ML, 60ML BOTTLE 2.50
METRONIDAZOLE (ZOLEMET) 5 MG/ML, 100 ML VIAL 23.00
METRONIDAZOLE (BRONAST) 5MG TABLET 70.00
MONTELUKAST (MONTEZYD) 10MG TABLET (NO TO OUT) 18.00
MONTELUKAST CAPSULE FOR ADULT 11.00
MULTIVITAMINS (BACTRIDERM) 2% CREAM, 15 GRAMS
MUPIROCIN (NALOCURE) 400 MCG/ML, 1 ML AMPULE 8.25
NALOXONE (AGYNAPIN) 1 MG/ML, 10 ML AMPULE 2.00
NICARDIPINE (NORTHIX) 1 MG/ML, 10 ML AMPULE 176.25
NOREPINEPHRINE 100,000 UNITS 30ML 329.50
NYSTATIN (VOMINO) 2 MG/ML, 2 ML AMPULE 268.50
ONDANSETRON (HYPERZOL) 40 MG CAPSULE 1,062.00
OMEPRAZOLE (HYPERZOL) 40 MG VIAL 195.00
OMEPRAZOLE (OXAFEN) 500 MG VIAL 255.00
OXACILLIN 10 IU/ML, 1ML AMPULE 6.75
OXYTOCIN 500 MG TABLET 32.75
PARACETAMOL (FEBRINIL) 150MG/ML, 2ML AMPULE 25.00
PARACETAMOL (KIDICEF) 250MG/5ML, 60ML 62.75
PARACETAMOL ( DEMETOR) 50MG/ML, 2ML AMPULE 1.25
PETHIDINE 30MG TABLET 5.50
PHENOBARBITAL 60MG TABLET 57.25
PHENOBARBITAL 90MG TABLET 192.50
PHENOBARBITAL 50MG/ML, 2ML AMPULE 4.25
PHENYTOIN (LANTIDIN) 50MG/ML, 2ML AMPULE 5.75
PHENYTOIN (MENARIGHT FORTE) 10MG/ML, 1ML AMPULE 7.25
PHYTOMENADIONE 555.00
PIPERACILLIN + (PIPZO) 4.5G VIAL (NO TO OUT) 108.50
TAZOBACTAM 68.25
POTASSIUM CHLORIDE (DYNA-K) 2 mEq.ML, 20 ML AMPULE
POTASSIUM CHLORIDE (KALIUM DURULES) 750 MG TABLET 585.00
POTASSIUM CITRATE (KAITRATE) 1080MG TABLET (30'S ONLY)
PROPOFOL (DIPRIFOL) 10MG/ML, 20ML AMPULE 40.50
PREDNISONE 10MG/5ML SUSPENSION 35.75
PROPRANOLOL (INDIRIN) 40MG TABLET (no to out)
PURIFIED RABIES VACCINE (SPEEDA) 2.5 IU/0.5ML VIAL 9.25
QUETIAPINE (SEROTIA) 100MG TABLET 80.75
QUETIAPINE (Q-WIN) 200MG TABLET 134.00
REMIFENTANIL ( SUBLIFEN) 1MG VIAL 13.25
RISPERIDONE (RISPEDIN) 2 MG TABLET 1,197.00
RIFAXIMIN (NORMIX) 200 MG TABLET 33.50
SALBUTAMOL 1 MG/ML, 2.5 ML NEBULE 40.25
1, 950.00

4.00
85.75
28.00

129 | P a g e

DRUGS AND MEDICINES DESCRIPTION RETAIL PRICE
SEVOFLURANE 250 ML BOTTLE 5,603.00
SEVOFLURANE (BAXTER) 250 ML BOTTLE 3,963.75
SILVER SULFADIAZINE (SILVEDERMA) 1% CREAM , 1 JAR 1,035.00
SODIUM BICARBONATE (SOLUNATE) 84MG/ML (8.4%), 20ML 348.00
SPIRONOLACTONE (DIURIX) 25 MG TABLET 15.25
SUXAMETHONIUM (ANEKTIL) 20MG/ML, 10ML VIAL 164.00
TAMSULOSIN (URITAM) 400MG TABLET 19.50
TETANUS
IMMUNOGLOBULIN (SEROTET) 250IU/ML, 1ML VIAL 975.00
TETANUS TOXOID
TOBRAMYCIN EYE DROP 0.5 ML AMPULE 45.00
TRAMADOL 0.3%, 5 ML BOTTLE SOLUTION 375.00
TRAMADOL (ROUNOX) 50MG CAPSULE
TRANEXAMIC ACID 50MG/ML, 2ML AMPULE 8.25
TRANEXAMIC ACID 500MG CAPSULE 9.75
TRIMETAZIDINE (CYCLOXID) 100MG/ML, 5ML AMPULE 24.00
VALPROIC ACID (TRIMEBET) 35MG TABLET 18.50
VITAMIN B COMPLEX (DEPAMAX) 250MG ER TABLET 7.25
100MG+100MG+1MG AMPULE (REPLACEMENT) 14.75
VITAMIN B COMPLEX (AMCOVIT-B) 100MG+10MG+50MCG TABLET (60'S 39.00
ONY)
ZINC SOLUTION 2.25
(ZINLUM) 20MG/5ML, 60ML
56.00

130 | P a g e

PHARMACY

Internal Service

131 | P a g e

1. Dispensing of Drugs and Medicines

This service involves dispensing of drugs and medicines to hospital personnel from the
time the client presents prescription until the time the client receives the drugs and
medicines. The cost of drugs and medicines shall be net of 20% discount and shall be
reported to payroll-in charge for salary deduction by the end of the month.

Availability of Service: Monday to Sunday (24 hours)

Office or Division: Pharmacy

Classification: Simple

Type of Transaction: G2G – Government to Government

Who may avail: All Hospital Personnel who wants to avail Salary Deduction

CHECKLIST OF REQUIREMENTS WHERE TO SECURE

1. Prescription (1 original copy) Emergency Room/Outpatient Department/

Requesting Physician

2. Order of Payment (1 original copy) Pharmacy

CLIENT STEPS AGENCY FEES PROCESSING PERSON
ACTIONS TO BE TIME RESPONSIBLE
PAID

3.1 Presents 1.1 Checks the None 3 minutes Pharmacist III

Prescription and completeness Pharmacy

receives and

instructions correctness of

the

prescription

and the

medicines.

1.1.1 Receives For unfilled None 2 minutes Pharmacist III
unfilled prescription prescription, Pharmacy
1.1.1 Returns
2. Receives and prescription if
acknowledges non-available
order of 2. Issues order of
payment
payment and
prepares
medicine

3. Checks dispensed 3. Dispenses None 3 minutes Pharmacist III
None Pharmacy
medicine and medicine/s

receives and gives

instruction/s if any instruction/s if

any

TOTAL 8 minutes

132 | P a g e

RADIOLOGY AND IMAGING SECTION

External Services

133 | P a g e

1. Availment of X-Ray Service for Out-Patient

This service involves the processing of availment for X-Ray Procedure/s from the time
the client presents the duly accomplished X-Ray Request Form until the client receives
the X-Ray result. In order for the client to avail the service, the following steps are to be
followed:

Availability of Service: Monday to Sunday (24 hours)

Office or Division: Radiology and Imaging Section

Classification: Complex

Type of Transaction: G2C - Government-to-Citizen

Who may avail: All Out-Patients

CHECKLIST OF REQUIREMENTS WHERE TO SECURE

For Conduct of Procedure:

1. Duly Accomplished X-ray Request Form OPD / ER

(1 original copy)

2. Charge Slip (1 original copy) RIS

For Releasing of Result:

1. Claim Slip (1 original copy) Radiology and Imaging Section

Admitting/Information Unit / OPD

2. Any Valid ID (1 photocopy/original GSIS, SSS, PagIbig, LTO, DFA, COMELEC,
copy) PhilHealth, BIR, PHLPost, LGU/Barangay, School,
Employer, Hospital
If by an Authorized Representative:
1. Any Valid ID of representative GSIS, SSS, PagIbig, LTO, DFA, COMELEC,
PhilHealth, BIR, PHLPost, LGU/Barangay, School,
(1 photocopy/original copy) Employer, Hospital

2. Any Valid ID of the Patient GSIS, SSS, PagIbig, LTO, DFA, COMELEC,
(1 photocopy/original copy) PhilHealth, BIR, PHLPost, LGU/Barangay, School,
Employer, Hospital

3. Authorization Letter from the patient Patient
(1 photocopy/original copy)
FEES
CLIENT STEPS AGENCY TO BE PROCESSIN PERSON
ACTIONS PAID G TIME RESPONSIBLE
None
1. Presents duly 1. Receives 5 minutes Radiologic
accomplished x- patient’s duly Technologist III
ray request form. accomplished Radiology and
x-ray request
2.a Receives charge form and Imaging
slip and proceeds checks for
to cashier for completeness None 5 minutes Radiologic
payment. of data Technologist III
Radiology and
2.a Issues order
of payment Imaging
and directs to
cashier for

134 | P a g e

payment of
charges.

*If patient will avail 2.b Processes None 17 minutes Social Welfare
for medical availment of Officer III
assistance medical 20 minutes
assistance. 2 minutes Medical Social Work
2.b Proceeds to MSW 30 minutes
for Availment of 5 minutes Administrative
medical Officer V
assistance.
Cash Operations
If with excess: *MSW on duty will Section
Proceeds to cashier stamped “MSS” on
the charge slip Radiologic
(Step 3) Technologist III
If no excess: 3. Issues official Please Radiology and
Proceeds to Step 4: receipt. refer to
3. Presents charge approved Imaging
*Cashier on duty schedule
slip and pay will stamped “Paid” of fees Radiologic
corresponding with OR Number on Technologist III
amount. the charge slip None Radiology and

4. Returns to 4. Receives Imaging
Radiology and Stamped paid
presents Stamped charge slip Radiologic
paid charge slip with OR Technologist III
with OR Number / number / MSS Radiology and
MSW Stamped Stamped
Charge Slip. charge slip. Imaging

5.1 Waits until name 5.1 Calls patient None
is called and for x-ray
submits self for x- procedure and
ray procedure. performs the
requested x-
ray procedure.

5.2 Acknowledges 5.2 Informs the None
schedule of x-ray patient when
result. to return for
the official
result. Issues
claim slip and
instructs client
to bring
required
documents
upon claiming
the result.

135 | P a g e

6.1 Returns to 6.1 Releases x- None 3 days Radiologic
releasing counter ray result to Technologist III
on the scheduled the patient. Radiology and
release of result
and presents Imaging
required
documents

6.2 Receives the X- 6.2 Issues X-Ray None 2 minutes Administrative Aide IV
Ray result and result and Radiology and
signs the releasing instructs client Please Imaging
logbook. to sign the refer to
releasing approved
logbook. schedule
of fees
TOTAL *Depends 3 days, 1 hour and 9 minutes
on the
discount For client that will avail financial
given assistance:

If with excess:
3 days, 1 hour and 26 minutes

If without excess:
3 days, 1 hour and 6 minutes

X-RAY PRICE LIST

(Effective September 1, 2020)

As per Hospital Order No. 452s. 2020

ITEM DESCRIPTION EXAMINATION UNIT RATE

1 VIEW CHEST X-RAY Php 200.00
A. ADULT PA Php 150.00
B. PEDIA AP/L Php 200.00

1 VIEW SKULL (ADULT/PEDIA) Php 350.00
Php 300.00
2 VIEWS UPPER AND LOWER EXTREMITIES Php 200.00

A. ADULT APL Php 400.00
B. PEDIA APL
Php 700.00
1 VIEW ABDOMEN X-RAY (ADULT/PEDIA PER
VIEW)

2 VIEWS SPINE (CERVICAL, THORACIC, LUMBAR)

ADULT/PEDIA PER VIEW

1 VIEW BABY GRAM

136 | P a g e

ITEM DESCRIPTION EXAMINATION UNIT RATE
Php 500.00
1 VIEW MOBILE X-RAY (ADULT/PEDIA PER VIEW) Php 1,500.00

1 PROCEDURE MAMMOGRAM UNIT RATE

ITEM DESCRIPTION EXAMINATION Php700.00
Php 800.00
1 PROCEDURE C-ARM
LESS THAN 30 MINUTES Php 1, 500.00
- WITH OUT PRINT Php 1, 500.00
- WITH PRINT
Php 500.00
30 MINUTES TO 1HR Php 700.00
- WITH OUT PRINT
- WITH PRINT

FOR EVERY BEYOND, AN ADDITIONAL OF
- WITH OUT PRINT
- WITH PRINT

137 | P a g e

2. Request for Schedule of Various Imaging Procedures

The Radiology and Imaging Department provides comprehensive diagnostic imaging
services. The service is open 24/7. Service takes in from the time the client presents
the duly accomplished Radiology and Imaging Request Form until the schedule is
given for the procedure.

Imaging procedures include:
●X-ray Special Procedure
●CT Scan
●Ultrasound
●2D Echo
●Mammogram

Availability of Service: Monday to Sunday (24 hours)

Office or Division: Radiology and Imaging

Classification: Simple

Type of Transaction: G2C - Government-to-Citizen

Who may avail: All (ER/OPD) Non-Admitted Clients

CHECKLIST OF REQUIREMENTS WHERE TO SECURE

1. Duly Accomplished Radiology and ER / OPD

Imaging Request Form (1 original copy)

2. Charge Slip (1 original copy) Radiology and Imaging

3. Contrast Media History and Radiology and Imaging

Assessment Form, if needed

(1 original copy)

4. Pertinent Clearances, if needed Requesting Physician

(1 original copy)

5. Bowel Preparation Instruction Form, if Radiology and Imaging

needed (1 original copy)

FEES

CLIENT STEPS AGENCY TO PROCESSING PERSON
ACTIONS
BE TIME RESPONSIBLE

PAID

1. Presents duly 1. Receives duly None 2 minutes Radiologic

accomplished accomplished Technologist III
Radiology and Radiology and Radiology and
Imaging Request Imaging
Imaging

Form Request Form

For x-ray special 2.1.a. Confirms None 30 minutes Radiologic
procedure & CT appropriateness Technologist III
Scan of data of the Radiology and
2.1.a. Submits self to requested
procedure and Imaging
Interview and review history of
Evaluation

138 | P a g e

patient and
checks
creatinine.

2.2.a. Signs patient’s 2.2.a. Instructs None 10 minutes Radiologic
consent, client to sign Technologist III
receives patient’s 15 minutes Radiology and
schedule and consent and 3 minutes
preparations gives schedule 17 minutes Imaging
and instructs on
the preparation Radiologic
of the Technologist III
procedure. Radiology and
Verifies the last
menstrual Imaging
period (if female
client). Radiologic
Technologist III
For Ultrasound, 2.1.b. Confirms None Radiology and
2D Echo & appropriatenes
Mammogram s of data, Please Imaging
2.1.b. Receives gives schedule refer to
and instructs approved Social Welfare
schedule & on the schedule Officer III
instruction on preparation of of fees
the preparation the procedure. Medical Social
of the Verifies the Work
procedure last menstrual
period (for
3.a Receives charge pelvic, TVS
slip and proceeds ultrasound &
to cashier for mammogram).
payment.
3.a Issues charge
slip and gives
the necessary
instructions for
the payment

*If patient will avail 3.b Processes None
for medical availment of
assistance medical
assistance.
3.b Proceeds to MSS
for availment of
medical
assistance.

139 | P a g e

If with excess: *MSW staff will
Proceed to cashier stamped
for Payment on the charge slip

If no excess: 4. Issues official Please 20 minutes Administrative
Proceeds to Step 4 receipt. refer to 2 minutes Officer V
4. Presents charge approved
*Cashier will schedule Cash Operations
slip and pays stamped “Paid” with of fees Section
corresponding OR number on the
amount and charge slip None Radiologic
returns to RIS. Technologist III
5. Instructs patient Radiology and
5. Receives to come back on
instruction on the specified date of Imaging
schedule of the schedule of the
procedure procedure.

TOTAL Please X-Ray Special Procedure & CT-
refer Scan:
to 1 hour and 7 minutes
approv
ed Ultrasound, 2D Echo &
sched Mammogram:
ule of 42 minutes
fees

For patient that will avail financial
assistance:

With excess:
X-Ray Special Procedure & CT-
Scan:
1 hour and 24 minutes

Ultrasound, 2D Echo &
Mammogram:
59 minutes
Without Excess:
X-Ray Special Procedure & CT-
Scan:
1 hour and 4 minutes

Ultrasound, 2D Echo &
Mammogram:
39 minutes

140 | P a g e

RADIOLOGY AND IMAGING DEPARTMENT
PRICELIST AS OF MARCH 22, 2022

EXAMINATION UNIT RATE
₱ 1,500.00
MAMMOGRAM
₱ 3,200.00
SPECIAL PROCEDURES (UPPER GI SERIES, SMALL BOWEL
SERIES, BARIUM ENEMA, ESOPHAGOGRAM, ₱ 1,400.00
CHOLANGIOGRAPHY, IVP AND VOIDING CYSTOGRAM) ₱ 1,500.00
₱ 1,500.00
ULTRASOUND EXAMINATION ₱ 1,000.00
WHOLE ABDOMEN ₱ 1,000.00
WHOLE ABDOMEN WITH PELVIC ₱ 1,000.00
WHOLE ABDOMEN WITH PROSTATE ₱ 1,200.00
UPPER ABDOMEN ₱ 1,000.00
LOWER ABDOMEN ₱ 900.00
KUB ₱ 1,000.00
KUBP ₱ 1,000.00
HEPATOBILIARY TREE ₱ 900.00
CHEST ₱ 1,000.00
CHEST WITH MARKINGS ₱ 900.00
NECK ₱ 800.00
THYROID ₱ 900.00
BREAST ₱ 900.00
CRANIAL ₱ 800.00
INGUINAL ₱ 800.00
SCROTAL ₱ 800.00
PROSTATE (TRANSRECTAL)
PROSTATE (TRANSABDOMEN) ₱ 5,500.00
SINGLE ORGAN ₱10,000.00
SOFT TISSUE SUPERFICIAL ₱ 5,500.00
DOPPLER ₱10,000.00
DOPPLER CAROTID (SINGLE) ₱ 5,500.00
DOPPLER CAROTID (BOTH) ₱10,000.00
DOPPLER UPPER EXTREMITY (SINGLE)
DOPPLER UPPER EXTREMITY (BOTH) ₱11,500.00
DOPPLER LOWER EXTREMITY (SINGLE)
DOPPLER LOWER EXTREMITY (BOTH)
INTERVENTION
ULTRASOUND GUIDANCE FOR NEEDLE REPLAGEMENT
(Aspiration, Biopsy, Injection, Localization, Device) with imaging
supervision and interpretation

141 | P a g e

EXAMINATION UNIT RATE
OB
PELVIC (Trans-abdomen) ₱ 900.00
PELVIC - Biophysical scoring ₱ 1,200.00
BIOPHYSICAL SCORING - DOPPLER FETAL/ ₱ 2,200.00

MATRIAL ₱ 2,000.00
PELVIC (Congenital anomaly scan) ₱ 500.00
PELVIC (Amniotic fluid index - only) ₱ 950.00
TRANSVAGINAL (TVS) ₱ 1,500.00
TRANSVAGINAL (TVS) 3D ₱ 2,700.00
SINGLETON 3D ₱ 3,200.00
SINGLETON 4D ₱ 3,200.00
TWIN 2D ₱ 3,700.00
TWIN 4D ₱ 3,000.00
TWIN (Congenita anomaly scan) ₱ 3,700.00
TRIPLET 3D ₱ 4,200.00
TRIPLET 4D ₱ 5,000.00
DOPPLER TWIN ₱ 800.00
PELVIC (Transabdomen) ₱ 950.00
PELVIC (Transrectal) ₱ 1,200.00
PELVIC (Transabdomen) 3D ₱ 850.00
TRANSVAGINAL ₱ 1,000.00
TRANSVAGINAL (DOPPLER) ₱ 5,000.00
HYSTEROSALPINGOSONOGRAPHY
₱ 3,650.00
CT SCAN EXAMINATION ₱ 4,600.00
CRANIAL PLAIN ₱ 5,000.00
CRANIAL WITH CONTRAST ₱ 6,100.00
FACIAL PLAIN ₱ 5,300.00
FACIAL WITH CONTRAST ₱ 6,600.00
CRANIO-FACIAL PLAIN ₱ 7,200.00
CRANIO-FACIAL WITH CONTRAST ₱ 5,000.00
CRANIO-FACIAL WITH 3D RECON ₱ 7,400.00
PHARYNX (ORO/NASO) PLAIN ₱ 5,100.00
PHARYNX (ORO/NASO) WITH CONTRAST ₱ 7,100.00
PARANASAL SINUSES PLAIN ₱ 5,100.00
PARANASAL SINUSES WITH CONTRAST ₱ 6,100.00
PITUITARY GLAND PLAIN ₱ 5,000.00
PITUITARY GLAND WITH CONTRAST ₱ 6,000.00
TEMPORAL BONE PLAIN ₱ 5,000.00
TEMPORAL BONE WITH CONTRAST
SELLA TURSICA PLAIN 142 | P a g e

EXAMINATION UNIT RATE
SELLA TURSICA WITH CONTRAST ₱ 6,000.00
MASTOIDS ₱ 4,500.00
ORBITS PLAIN ₱ 4,200.00
ORBITS WITH CONTRAST ₱ 6,100.00
NECK PLAIN ₱ 5,000.00
NECK WITH CONTRAST ₱ 6,100.00
CHEST PLAIN ₱ 5,000.00
CHEST WITH CONTRAST ₱ 6,300.00
CHEST HR PLAIN ₱ 7,600.00
WHOLE ABDOMEN PLAIN ₱ 6,400.00
WHOLE ABDOMEN WITH CONTRAST ₱ 8,600.00
UPPER ABDOMEN PLAIN ₱ 5,600.00
UPPER ABDOMEN WITH CONTRAST ₱ 6,350.00
LOWER ABDOMEN PLAIN ₱ 5,600.00
LOWER ABDOMEN WITH CONTRAST ₱ 6,350.00
TRIPHASIC LIVER SCAN ₱ 9,200.00
STONOGRAM ₱ 6,000.00
PELVIS PLAIN ₱ 4,500.00
PELVIS WITH CONTRAST ₱ 5,400.00
SPINE : CERVICAL PLAIN ₱ 4,500.00
₱ 6,000.00
CERVICAL WITH CONTRAST ₱ 6,000.00
THORACIC PLAIN ₱ 6,500.00
THORACIC WITH CONTRAST ₱ 6,000.00
LUMBAR PLAIN ₱ 6,500.00
LUMBAR WITH CONTRAST ₱ 4,000.00
JOINTS PLAIN ₱ 5,100.00
JOINTS WITH CONTRAST ₱ 4,000.00
SINGLE ORGAN ₱ 5,000.00
EXTREMITIES PLAIN ₱ 7,000.00
EXTREMITIES WITH CONTRAST ₱10,100.00
CT ANGIORAM ₱ 7,000.00
CT-GUIDED BIOPSY
2D ECHO EXAMINATION ₱ 3,500.00
2D ECHO WITH DOPPLER ₱ 2,000.00
2D ECHO SCAN
143 | P a g e

3. Conduct of Procedure and Releasing Result for 2D Echo and
Doppler Ultrasound of Out-Patient

This service involves processing for conduct of procedure and releasing of result for
2D echo and Doppler ultrasound that takes in from the time the client comes back for
the 2D Echo procedure and Doppler Ultrasound until the releasing of official result.

Availability of Service: Monday to Sunday (24 hours)

Office or Division: Radiology and Imaging

Classification: Complex

Type of Transaction: G2C - Government-to-Citizen

Who may avail: All Scheduled Patients (Non-Admitted Clients) for the Procedure

CHECKLIST OF REQUIREMENTS WHERE TO SECURE

For Conduct of Procedure:

1. Duly Accomplished Request Form ER/OPD

(1 original copy)

2. Stamped “Paid” / MSS stamped charge Cash Operation Office / MSW Section

slip (1 original copy)

3. Pertinent Clearances, if needed Requesting doctor

(1 original copy)

For Releasing of Result:

1. Claim Slip (1 original copy) Radiology and Imaging

Admitting/Information Unit / OPD

2. Any Valid ID (1 photocopy/original GSIS, SSS, PagIbig, LTO, DFA, COMELEC,
copy)
PhilHealth, BIR, PHLPost, LGU/Barangay,

School, Employer, Hospital

FEES

CLIENT STEPS AGENCY TO PROCESSING PERSON
ACTIONS
BE TIME RESPONSIBLE

PAID

1. Presents 1. Receives None 5 minutes Radiologic
documentary documentary
requirements and requirements Technologist III
goes to waiting then instructs
area patient to Radiology and
proceed to
2.1 Waits until name is designated Imaging
called and submits waiting area.
self for the None 5 minutes Radiologic
procedure. 2.1 Calls patient Technologist III
name and Radiology and
instructs
patient on Imaging
what to do.

2.2 Undergoes 2.2 Conducts None 2D Echo : Radiologic
procedure procedure 1hour Technologist III
Radiology and
Doppler Utz :
4 hours Imaging

144 | P a g e

3. Receives claim slip 3. Issues claim None 5 minutes Radiologic
slip and None Technologist III
4.1 Returns to instructs to 2D Echo : Radiology and
releasing counter bring the claim 5 days
on the scheduled slip together Imaging
release of result with any valid Doppler UTZ:
then submits claim ID upon Simple Case: Radiologic
slip and presents claiming the Technologist III
any valid ID for result on 3 days Radiology and
verification. specified date. Complicated:
Imaging
4.1 Receives the 5 days
claim slip
together with
required
document and
releases
official result to
the patient.

4.2 Signs the releasing 4.2 Let the patient None 2 minutes Administrative
logbook signs the Aide IV
releasing
logbook. Radiology and
Imaging

TOTAL None 2D Echo:
5 days,1 hour & 17 minutes

Doppler UTZ:
Simple Case:
3, days, 4 hours & 17 minutes

Complicated:
5 days, 4 hours & 17 minutes

145 | P a g e

4. Conduct of Procedure and Releasing Result for Mammogram of Out-
Patient

This service involves the processing of conduct for procedure and releasing of results
for mammogram that takes in from the time the client comes back and presents
required documents for the Mammogram procedure until the releasing of official
result.

Availability of Service: Procedure: Monday to Friday, 8AM-5PM
Releasing of Official Results: Monday to Sunday
(24 Hours)

Office or Division: Radiology and Imaging

Classification: Highly Technical

Type of Transaction: G2C - Government-to-Citizen

Who may avail: All Scheduled Patients for Procedure

CHECKLIST OF REQUIREMENTS WHERE TO SECURE

For Conduct of Procedure:

1. Duly Accomplished Request Form ER/OPD

(1 original copy)

2. Stamped “Paid” / MSS stamped charge Cash Operation Office / MSW Section

slip (1 original copy)

3. Pertinent Clearances, if needed Requesting doctor

(1 original copy)

For Releasing of Result:

1. Claim Slip (1 original copy) Radiology and Imaging

Admitting/Information Unit / OPD

2. Any Valid ID (1 photocopy/original GSIS, SSS, PagIbig, LTO, DFA, COMELEC,
copy)
PhilHealth, BIR, PHLPost, LGU/Barangay,

School, Employer, Hospital

FEES

CLIENT STEPS AGENCY TO PROCESSING PERSON
ACTIONS
BE TIME RESPONSIBLE

PAID

1. Presents 1. Receives None 5 minutes Radiologic
documentary documentary
requirements and requirements Technologist III
goes to waiting then instructs
area patient to Radiology and
proceed to
2.1 Waits until name is designated Imaging
called and submits waiting area.
self for the None 5 minutes Radiologic
procedure. 2.1 Calls patient Technologist III
name and Radiology and
instructs
patient on Imaging
what to do.

146 | P a g e

2.2 Undergoes 2.2 Conducts None 30 minutes Radiologic
procedure procedure Technologist III
Radiology and
3. Receives claim slip 3. Issues claim None 5 minutes
slip and None 7 days Imaging
4.1 Returns to instructs to Radiologic
releasing counter bring the claim Technologist III
on the scheduled slip together Radiology and
release of result with any valid
then submits claim ID upon Imaging
slip and presents claiming the
any valid ID for result on Radiologic
verification. specified date. Technologist III
Radiology and
4.1 Receives the
claim slip Imaging
together with
required
document and
releases
official result to
the patient.

4.2 Signs the releasing 4.2 Let the patient None 2 minutes Administrative
logbook signs the Aide IV
releasing
logbook. Radiology and
Imaging

TOTAL None 7 days and 47 minutes

147 | P a g e

5. Conduct of Procedure and Releasing of Ultrasound Result for Out-
Patient

This service involves processing the conduct of ultrasound procedure and releasing
of result after the client returns on his/her scheduled procedure.

Availability of Service: Procedure:
Ultrasound: Monday to Sunday, 8AM-12NN, 1PM-5PM
Releasing of Official Results: Monday to Sunday
(24 Hours)

Office or Division: Radiology and Imaging

Classification: Simple

Type of Transaction: Government-to-Citizen

Who may avail: All Scheduled Patients (Non-Admitted Clients) for the Procedure

CHECKLIST OF REQUIREMENTS WHERE TO SECURE

For Conduct of Procedure:

1. Duly Accomplished Request Form ER/OPD

(1 original copy)

2. Stamped “Paid” / MSS stamped charge Cash Operation Office / MSW Section

slip (1 original copy)

3. Pertinent Clearances, if needed Requesting doctor

(1 original copy)

For Releasing of Result:

4. Claim Slip (1 original copy) Radiology and Imaging

Admitting/Information Unit / OPD

5. Any Valid ID (1 photocopy/original GSIS, SSS, PagIbig, LTO, DFA, COMELEC,
copy)
PhilHealth, BIR, PHLPost, LGU/Barangay,

School, Employer, Hospital

FEES

CLIENT STEPS AGENCY TO PROCESSING PERSON
ACTIONS
BE TIME RESPONSIBLE

PAID

1. Presents 1. Receives None 5 minutes Radiologic
documentary documentary
requirements and requirements Technologist III
goes to waiting then instructs
area patient to Radiology and
proceed to
2.1 Waits until name is designated Imaging
called and submits waiting area.
self for the None 5 minutes Radiologic
procedure. 2.1 Calls patient None 1 hour Technologist III
name and Radiology and
2.2 Undergoes instructs
procedure patient on Imaging
what to do.
Medical Specialist
2.2 Conducts III
procedure
Radiology and

148 | P a g e

Imaging

3. Receives claim slip 3. Issues claim None 5 minutes Radiologic
slip and None Technologist III
4.1 Returns to instructs to Simple Case: Radiology and
releasing counter bring the claim 1 day
on the scheduled slip together Imaging
release of result with any valid Complicated:
then submits claim ID upon 2 days Radiologic
slip and presents claiming the Technologist III
any valid ID for result on Radiology and
verification. specified date.
Imaging
4.1 Receives the
claim slip
together with
required
document and
releases
official result to
the patient.

4.2 Signs the releasing 4.2 Let the patient None 2 minutes Radiologic
logbook signs the Technologist III
releasing Radiology and
logbook.
Imaging

TOTAL None Simple case:
1 day, 1 hour and 17 minutes

Complicated case:
2 days, 1 hour and 17 minutes

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