Licensure rules for ambulances and services

Legal basis, prior issuances, and intent

The licensing standards were developed pursuant to Administrative Order (A.O.) No. 2010-0003 establishing a National Policy on Ambulance Use and Services, including a requirement that the relevant bureau establish licensing standards and ensure implementation through regulation.
The framework also addresses misuse of ambulance vehicles and the mislabeling of other vehicles as ambulances, and it is intended to ensure competent personnel, appropriate equipment, quality care, and patient safety.
A prior licensing regulation, A.O. No. 2016-0029 (titled “Rules and Regulations Governing the Licensure of Ambulances and Ambulance Service Providers”, dated June 29, 2016), is revised by this order.
A compliance moratorium previously extended under Department Circular (D.C.) No. 2016-0357 was used to allow stakeholders time to comply until December 31, 2017, pending review.

Covered ambulances and license coverage

These rules apply to all government and private land ambulances and ambulance service providers (ASP).
The license authority is DOH-LTO, which is a formal authorization issued by the Department of Health to operate an ambulance.
Institutional-based ambulance ambulances obtain DOH-LTO through the One-Stop Shop (OSS) system for hospitals and other health facilities, and the ambulances’ licenses are reflected in the health facility DOH-LTO.
Non-institution-based ambulances require a separate DOH-LTO.
Patient Transport Vehicles (PTVs) are treated as vehicles for non-life threatening patient transport and follow registration rules rather than HFSRB licensure rules.

Definitions that govern interpretation

Ambulance is defined as a vehicle designed and equipped for transporting sick or injured patients to, from, and between places of treatment by land, water or air, affording safety and comfort and avoiding aggravation of illness or injury.
Ambulance Service Provider (ASP) is a health facility, institution, or entity—government or privately owned—providing ambulance services.
Basic Life Support (BLS) covers actions and interventions used to resuscitate and stabilize victims of cardiac or respiratory arrest, including recognition of emergency/stroke, activation of the emergency response system, CPR, and relief of foreign body airway obstruction.
Advance Life Support (ALS) extends BLS with life-saving protocols and skills supporting circulation, opening the airway, adequate ventilation, and includes interventions such as advanced airway management, tracheal intubation, medications, electrical therapy, and intravenous (IV) access.
Emergency Medical Technician (EMT) is defined as a trained professional providing out-of-hospital emergency medical care and transportation for critical and emergent patients accessing the EMS system.
Patient Transport Vehicle (PTV) is defined as any form of land vehicle designed to transport patients whose condition is of a non-life threatening nature.
HFSRB is defined as the Health Facilities and Services Regulatory Bureau.
RO-RLED is defined as the Regional Office—Regulation Licensing and Enforcement Division.
Medical Direction allows a paramedic or EMT to contact a physician from the field via radio or other means to obtain instruction on further care of a patient.
Medical emergencies are defined as any acute or life-threatening condition requiring immediate intervention by competent personnel.

General operating standards and vehicle rules

Ambulance vehicles must be duly registered with the Land Transportation Office under the name of the ambulance service provider prior to applying for a DOH-LTO.
Licensed land ambulances must be used only for the purpose for which they are licensed.
No land vehicle may bear on its body the label/marking “AMBULANCE” unless it has been duly licensed and categorized as a land ambulance by the Department of Health.
An ambulance service provider must be organized to provide safe, quality, effective, and efficient ambulance services available at all times.
Privately owned ambulance service providers must be registered with DTI or SEC, whichever is applicable.
Government-owned ambulance service providers must present a local government ordinance/board resolution or its equivalent as proof of ownership.
Every ASP must have an Operations Control and Dispatch Center (business office or space) and must ensure adequate parking spaces for its ambulances.
Every ASP must operate within a functional referral network in its area of operation.
An ASP must strictly comply with the standards and requirements in the Assessment Tool for Licensing a Land Ambulance and Ambulance Service Provider (Annex C).
Each ambulance vehicle must undergo inspection; only vehicles found compliant may be added to the approved list, and vehicles no longer used as ambulances must be delisted by notifying HFSRB/RO-RLED through a letter indicating the plate or conduction sticker number, after which the vehicle must no longer bear “AMBULANCE” markings and the DOH Ambulance logo must be removed.
Vehicles used to transport patients without BLS or ALS capability must be categorized as Patient Transport Vehicles (PTV).
PTVs may transport patients whose condition is of a non-life threatening nature, including scheduled visits for treatment, routine examinations, x-rays or laboratory tests, or upon discharge from a hospital.
PTVs should not bear the marking “AMBULANCE” and must instead be labeled “PATIENT TRANSPORT VEHICLE.”
PTVs shall not be licensed by HFSRB but must be registered with the bureau using a prescribed form.

Classification, required categories, and ambulance standards

Land ambulances are classified according to ownership: Government (wholly managed and operated by government agencies/institutions including, among others, DOH hospitals, LGUs and LGU-run hospitals, BFP, PNP, Philippine Coastguard, AFP, MMDA) and Private (owned and managed with funds through donation, principal, investment, or other means by individuals, corporations, associations, organizations, including single proprietorship, partnership, corporation, cooperative, foundation, religious, non-government organization and others).
Land ambulances are also classified according to institutional character: Institution-based (owned, operated, maintained, and used by a DOH-regulated health facility such as a hospital or infirmary) and Non-institution-based/Free-Standing (operated independently from a health facility but may service a health facility through a notarized MOA/service contract or equivalent).
Land ambulances are categorized by capability: Type I provides BLS, and Type II provides ALS.
The category of ambulance required for health facilities must be commensurate with service level shown in the table:
- Specialty and Level 3 Hospitals require Type II (ALS) Ambulance when outsourced with a DOH-licensed ASP; the ambulance must be stationed at the hospital at all times and a MOA must exist between the hospital and the ASP.
- Level 2 Hospitals and Level 1 Hospitals require Type I (BLS) Ambulance for outsourced arrangements; they must enter into a MOA with a DOH-licensed ASP, and Level 2/Level 1 hospitals may opt to have a Type II ambulance for Level 1 hospitals’ outsourced ambulance services.
Infirmaries may require ambulances in the same table framework, and they may opt to have their own Patient Transport Vehicles (PTV) in addition to ambulances.
Birthing facilities must enter a MOA with ambulance service providers (government or privately owned) at a minimum, may opt to own an ambulance, and a single MOA suffices when the birthing home referral facility is also the ambulance service provider, provided ambulance service terms are clearly stipulated.
All facilities entering into MOA/s with any DOH-licensed ASP must consider that the ASP can respond and provide ambulance services within a reasonable time, consistent with its service capacity and capability.

Ambulance body and markings

An ambulance must be able to accommodate the patient, the required number of personnel, and equipment.
An ambulance must have a non-porous partition between the driver and the body.
DOH-licensed ambulances must bear reflectorized and capitalized “AMBULANCE” markings with specified visibility and size:
- Front: “AMBULANCE” spelled in reverse (mirror image), each letter at least 10 centimeters, readable from at least six (6) meters.
- Side: “AMBULANCE” on each side at least 15 centimeters high; the licensee name/logo and administrative division may be indicated so long as the logo/font size does not exceed the word height, placed below the word “AMBULANCE.”
- Rear: “AMBULANCE” at least 15 centimeters high and the prescribed DOH ambulance logo issued upon license approval.
The licensee may mount a blue “Star of Life” emblem on any part of the ambulance vehicle.
No restrictions apply to the color of the ambulance vehicle or lettering.
Any signage/pictures outside prescribed markings are not allowed.

Personnel qualification requirements by type and year

Each ambulance must be manned by an adequate number of qualified, trained, competent staff for efficient and effective delivery of quality ambulance services.
At least two (2) ambulance personnel, excluding the driver, must be present for every ambulance dispatched. Additional staff depends on emergency nature as determined by the ASP’s management.
Minimum personnel qualifications and training differ by ambulance type:

Type I (BLS)
- Minimum qualification: a Graduate of any health related 4 year course.
- CY 2018–2019 training: Standard First Aid (SFA) and Basic Life Support (BLS).
- Starting CY 2020: SFA + BLS + Emergency Medical Technician (EMT) Training + Basic (training requirement continues as stated under the order’s Type I transition wording).
Type II (ALS)
- Minimum qualification: a Licensed or Registered Nurse (RN).
- CY 2018 training: Standard First Aid (SFA) + Basic Life Support (BLS) + Advance Cardiac Life Support (ACLS).
- Starting CY 2020: SFA + BLS + ACLS + EMT Training + Advance/Paramedic Training.
The ASP must maintain a staff development and continuing education program to upgrade knowledge, attitude, and skills.

Equipment, maintenance, supplies, and contingency

Every ambulance must have available and operational prescribed equipment, medicines, and supplies consistent with Annex C.
The ASP must implement calibration, preventive maintenance, and repair programs, including decontamination and disinfection.
The ASP must maintain a contingency plan for equipment breakdown/malfunction, especially during patient transport.
The ASP must implement a program for management of temperature-sensitive medication.

Service delivery and SOP/referral obligations

Ambulance services must comply with the standard quality embodied in Annex C, other policy guidelines, and related issuances.
The ASP must maintain documented policies and procedures (administrative and technical Standard Operating Procedures (SOP)) for ambulance service delivery.
The ASP must maintain documented policies and procedures establishing its referral system.
Non-institution-based/free-standing ambulance providers servicing the public independently must have a MOA with a hospital for needed health services, except in extreme medical emergencies or when patients prefer another ambulance service provider.
Ambulances must have devices to communicate with the ASP’s operation center and the referral hospital/health facility for case recording and management.
Medical direction guidelines must be implemented when needed.

Information management, confidentiality forms, logbooks, and annual reports

The ASP must maintain a system for communication, recording, and reporting of patient condition and examination results, including electronic communications where allowed under Republic Act No. 8792 (Electronic Commerce Act of 2000).
Data management must adhere to Republic Act No. 10173 (Data Privacy Act of 2012).
The Hospital/Facility Referral Form must be kept confidential and must contain enough information to identify the patient and justify treatment, including transfer/referral details.
The ASP must maintain a logbook and ensure it is signed by the head of the DOH licensing team during inspection and/or monitoring visits. The logbook must include, at minimum:
- patient name, sex, and age;
- name of attending physician when applicable;
- origin and destination, and date/time of dispatch and return;
- reason for transfer/transport; and
- patient disposition.
The ASP must submit an annual report using the DOH template (Annex D: DOH Annual Statistical Report for Ambulance Service Providers), due every 31st of March of the following year (e.g., CY 2018 report due March 31, 2019).

Environmental management and infection control

The ASP must ensure an environment safe for patients and staff, and as necessary for the public.
The ambulance must be properly ventilated, lighted, clean, and safe.
The ASP must implement written disinfection and preventive maintenance plans for vehicles.
PPE use and adherence to infection control policies must be strictly observed.
The ASP must implement procedures for proper disposal of infectious wastes and toxic/hazardous substances consistent with Republic Act No. 6969 and other related policy guidelines and issuances.

Licensing procedure: applications, timelines, and OSS

The DOH-LTO application process is handled by HFSRB and RO-RLED, and application processing is completed within thirty (30) days from receipt of complete application documents, covering issuance or non-issuance.
Processing depends on application type and whether ambulances are institution-based or non-institution-based:
- Institution-based ambulances follow OSS for hospitals and other health facilities.
- Non-institution-based ambulances use consecutive steps with HFSRB/RO-RLED evaluation and inspection.
For initial DOH-LTO for non-institution-based ambulances, the ASP must submit:
- a duly accomplished application form downloadable from hfsrb.doh.gov.ph;
- proof of ownership:
  - for government-owned ambulances: enabling act or board resolution (or equivalent) and CDA registration with articles of cooperation and by-laws whenever applicable;
  - for privately owned ambulances: DTI or SEC registration with articles of incorporation and by-laws, plus CDA registration with articles of cooperation and by-laws whenever applicable;
- registration of the vehicle(s) with the Land Transportation Office; and
- driver/s’ professional driver license from the Land Transportation Office.
For initial DOH-LTO, the applicant must pay the corresponding fee and submit a copy of the official receipt to HFSRB/RO-RLED.
HFSRB/RO-RLED evaluates completeness; a complete application means required documents as in the application checklist are submitted.
If the application is incomplete, the applicant is given thirty (30) days to submit complete documentary requirements.
Payment is forfeited if complete documents are not submitted within thirty (30) days.
For complete applications, HFSRB/RO-RLED inspection must occur, with the applicant ensuring key staff, records, and ambulance vehicles are available during inspection.
If inspection finds non-compliance, HFSRB/RO-RLED issues deficiencies notice and provides time to comply within a maximum of thirty (30) days; during compliance period, application processing stops using an “stop-clock” rule until deficiencies are complied with.
Failure to complete compliance within the given timeline results in disapproval and forfeiture of payment, and HFSRB/RO-RLED sends a Letter of Denial with noted deficiencies.
If found compliant, the inspection team recommends issuance of the DOH-LTO.
The issuance is approved by Director IV of HFSRB/RO, or Director III in absence/unavailability or when delegated.
After issuance, compliant ambulances are provided the Official DOH Ambulance Logo with corresponding plate or conduction sticker number, ambulance category, and validity year for DOH-LTO validity, mounted at the rear of the vehicle, and each ambulance must have a copy of the ASP DOH-LTO.

Renewal, cancellation, monitoring, and suspension

For renewal of DOH-LTO:
- institution-based ambulance providers follow OSS; and
- non-institution-based providers submit a duly accomplished application form, the DOH annual ambulance statistical report, and other relevant records that DOH may require, while applying the same steps and timelines used for initial non-institution-based applications.
A provider’s DOH-LTO is cancelled automatically without notice if the provider fails to submit a duly accomplished application form and to pay the proper fee beyond thirty (30) days from the date of expiration stated in the license; thereafter the provider applies for an initial DOH-LTO.
Licensed ambulance service providers and ambulances are monitored regularly by HFSRB or RO-RLED using the Annex C assessment tool.
During monitoring, the applicant must make available all key staff, records, premises, and facilities.
A Notice of Violation is issued immediately for non-compliance with these rules and regulations.

License validity and fee handling

The DOH-LTO for institution-based ambulance providers is valid for one (1) year only following the OSS system for hospitals and other health facilities.
The DOH-LTO for non-institution-based ASPs is valid for three (3) years, running from January of the first year to December of the third year.
A non-refundable fee is charged for the DOH-LTO application of an ambulance service provider and its land ambulances, under the Annex E: Schedule of Fees.
Fees/checks must be paid to the order of DOH in person or through postal money order; the order also provides for payment through bank to bank payments as soon as the system becomes functional.
Fees, surcharges, and discounts follow the current DOH prescribed schedule under:
- A.O. No. 2007-0001 (Revised Schedule of Fees for Certain Services Rendered by the Bureau of Health Facilities and Services and Centers for Health Development),
- A.O. No. 2007-0023 (Schedule of Fees for the One-Stop Shop Licensure System for Hospitals), and
- A.D. No. 2008-0028 (Schedule of Fees for the One-Stop Shop System for the Regulation of Medical Facilities for Overseas Workers and Seafarers and Non-Hospital Based, and related facilities).

Violations, administrative action, penalties, and revocation

Any ambulance service provider that violates any provision of these rules, related issuances, or relevant policy guidelines, or commits acts/omissions by personnel operating under the order, is penalized and/or may have its DOH-LTO suspended or revoked.
HFSRB or the Regional Office Director and/or authorized representatives investigate complaints and verify alleged violations.
The HFSRB or Regional Office Director may impose preventive suspension of operation pending investigation for a period not more than ninety (90) days.
Imposable penalties for violations are governed by A.O. No. 2007-0022 (Violations under the One-Stop Shop Licensure System for Hospitals), A.O. No. 2008-0027 (One-Stop Shop System for the Regulation of Medical Facilities for Overseas Workers and Seafarers, Non-Hospital-Based Dialysis Clinics and Non-Hospital-Based Ambulatory Surgical Clinics with Ancillary Services), and related issuances or guidelines.
If death or serious physical injury occurs to the patient, passengers, pedestrians, or general public and the death/injury is determined by the appropriate authority to be due to negligence or misuse of the ambulance, the ambulance service provider’s DOH-LTO is automatically revoked. This automatic revocation does not prevent criminal or civil charges by the aggrieved party.
Providers whose DOH-LTO has been revoked are prohibited from applying for another DOH-LTO as an ASP for a minimum of one (1) year.

Appeals and final executory decisions

Any hospital or other health facility aggrieved by the decision of the HFSRB Director or Regional Director may file a notice of appeal to the Head of the Office for Health Regulation (OHR) within ten (10) days from receipt of the notice of decision.
HFSRB or the Regional Office elevates the appellant’s pertinent documents and records to the OHR.
If the decision of the OHR remains contested, it may be brought to a final appeal to the Secretary of Health within ten (10) days from receipt of the OHR decision.
The Secretary of Health’s decision is absolute and executory.

Transitory, repealing, separability, and enforcement

For CY 2018 DOH-LTO applications, both institution-based and non-institution-based ambulance providers may file applications and pay corresponding fees at HFSRB or RO-RLED until December 15, 2017.
Applications filed starting January 2018 must follow the general application procedures under Section VII.A.
Inconsistent or contrary provisions in previous issuances are amended or revoked by implication or expressly by this order via its repealing clause.
If any provision or part of the order is declared unauthorized or invalid by a court of law, the remaining provisions not affected remain valid and in force.