REPUBLIC OF THE PHILIPPINES

PROVINCE OF BATANGAS
MUNICIPALITY OF TAAL

RURAL HEALTH UNIT I

CERTIFICATION OF SERVICE DELIVERY SUPPORT

(Medicines)

This is to certify that our institution is FDA licensed and is contracted referral facility and/or service provider in behalf of
RURAL HEALTH UNIT -TAAL for the PhilHealth Konsulta Package from _____________________. As a Service
Delivery partner, we shall provide the following services:
All PhilHealth Konsulta Drugs Specific Drug/s (please check)
Amlodipine 10 mg Tablet (As Besilate) Co-Amoxiclav 125 mg amoxicillin (as trihydrate) + 31
(Amoxicillin + mg potassium clavulanate per 5 mL
Potassium Clavulanate) granules/powder for suspension, 30
mL
Amlodipine 5 mg Tablet (As Besilate) Co-Amoxiclav 125 mg amoxicillin (as trihydrate) + 31
(Amoxicillin + mg potassium clavulanate per 5 mL
Potassium Clavulanate) granules/powder for suspension, 60 mL
Amoxicillin 125 mg/5mL, 60 mL Suspension Co-Amoxiclav 200 mg amoxicillin (as trihydrate) + 28.5
(Amoxicillin + mg potassium clavulanate per 5 mL
Potassium Clavulanate) granules/powder for suspension, 70
mL
Amoxicillin 250 mg/5mL, 60 mL Suspension Co-Amoxiclav 250 mg amoxicillin (as trihydrate) + 62.5
(Amoxicillin + mg potassium clavulanate per 5 mL
Potassium Clavulanate) granules/powder for suspension, 60
mL
Amoxicillin 250 mg Capsule Co-Amoxiclav 250 mg amoxicillin (as trihydrate) + 62.5
(Amoxicillin + mg potassium clavulanate per 5 mL
Potassium Clavulanate) granules/powder for susp, 100 mL
Amoxicillin 500 mg Capsule Co-Amoxiclav 400 mg amoxicillin (as trihydrate) + 57
(Amoxicillin + mg potassium clavulanate per 5 mL
Potassium Clavulanate) granules/powder for suspension, 30
mL
Amoxicillin 100 mg/mL, 10 mL Drops Co-Amoxiclav 400 mg amoxicillin (as trihydrate) + 57
(Amoxicillin + mg potassium clavulanate per 5 mL
Potassium Clavulanate) granules/powder for suspension, 70
mL
Aspirin 80 mg enteric-coated tablet Cotrimoxazole 400 mg sulfamethoxazole + 80 mg
(Sulfamethoxazole + trimethoprim tablet
Trimethoprim)
Asprin 100 mg enteric-coated tablet Cotrimoxazole 400 mg sulfamethoxazole + 80 mg
(Sulfamethoxazole + trimethoprim capsule
Trimethoprim)
Chlorphenamine 4 mg Tablet Cotrimoxazole 800 mg sulfamethoxazole + 160 mg
(Sulfamethoxazole + trimethoprim tablet
Trimethoprim)
Chlorphenamine 2.5 mg/5mL syrup, 60 mL Cotrimoxazole 200 mg sulfamethoxazole + 40 mg
(Sulfamethoxazole + trimethoprim/5mL suspension 30
Trimethoprim) mL Bottle
Ciprofloxacin 250 mg Tablet (as HCI) Cotrimoxazole 200 mg sulfamethoxazole + 40 mg
(Sulfamethoxazole + trimethoprim/5mL suspension 60
Trimethoprim) mL
Bottle
Ciprofloxacin 500 mg Tablet (as HCI) Cotrimoxazole 200 mg sulfamethoxazole + 40 mg
(Sulfamethoxazole + trimethoprim/5mL suspension 70
Trimethoprim) mL
Bottle
Clarithromycin 250 mg base Tablet Cotrimoxazole 200 mg sulfamethoxazole + 40 mg
(Sulfamethoxazole + trimethoprim/5 mL suspension 100
Trimethoprim) mL Bottle
Clarithromycin 500 mg base Tablet Cotrimoxazole 400 mg sulfamethoxazole + 80 mg
(Sulfamethoxazole + trimethoprim/5mL suspension
Trimethoprim) 30mL Bottle
Clarithromycin 500 mg MR tablet Cotrimoxazole 400 mg sulfamethoxazole + 80 mg
(Sulfamethoxazole + trimethoprim/5mL suspension
Trimethoprim) 60mL
Bottle
Clarithromycin 125 mg/5 mL granules/powder for Enalapril 5 mg Tablet (As Maleate)
suspension, 60 mL
Co-Amoxiclav (Amoxicillin + 250 mg amoxicillin (as trihydrate) + 125 Enalapril 10 mg Tablet (As Maleate)
Potassium Clavulanate) mg potassium clavulanate per tablet
Co-Amoxiclav (Amoxicillin + 500 mg amoxicillin (as trihydrate) + 125 Fluticasone + Inhalation: DPI
Potassium Clavulanate) mg potassium clavulanate per tablet Salmeterol 100 micrograms fluticasone (as
propionate) + 50 micrograms salmeterol
(as xinafoate) x 28 doses with appropriate
accompanying dispenser
Co-Amoxiclav (Amoxicillin + 875 mg amoxicillin (as trihydrate) + 125 Fluticasone + Inhalation: DPI
Potassium Clavulanate) mg potassium clavulanate per tablet Salmeterol 100 micrograms fluticasone (as
propionate) + 50 micrograms salmeterol
(as xinafoate) x 60 doses with appropriate
accompanying dispenser
 Fluticasone + Salmeterol Inhalation: DPI Prednisone 10 mg Tablet
250 micrograms fluticasone (as
propionate) + 50 micrograms salmeterol
(as xinafoate) x 28 doses and with
appropriate accompanying dispenser
Fluticasone + Salmeterol Inhalation: DPI Prednisone 10 mg /5 mL, 60 mL Suspension
500 micrograms fluticasone (as
propionate) + 50 micrograms salmeterol
(as xinafoate) x 60 doses with appropriate
accompanying dispenser
Fluticasone + Salmeterol Inhalation: DPI Prednisone 20 mg Tablet
250 micrograms fluticasone (as
propionate) + 50 micrograms salmeterol
(as xinafoate) x 60 doses with appropriate
accompanying dispenser
Fluticasone + Salmeterol Inhalation: DPI Prednisone 5 mg Tablet
500 micrograms fluticasone (as
propionate) + 50 micrograms salmeterol
(as xinafoate) x 28 doses with appropriate
accompanying dispenser
Gliclazide 30 mg MR Tablet Salbutamol 2 mg tablet (as sulfate)
Gliclazide 80 mg MR Tablet Salbutamol 4 mg MR tablet (as sulfate)
Hydrochlorothiazide 12.5 mg Tablet Salbutamol 8 mg MR tablet (as sulfate)
Hydrochlorothiazide 25 mg Tablet Salbutamol 2 mg/5 mL syrup, 60 mL (as sulfate)
Hydrochlorothiazide 50 mg Tablet Salbutamol MDI:
100 micrograms/dose x 200 doses
(as sulfate)
Losartan 50 mg Tablet (as potassium salt) Salbutamol Breath-Actuated MDI (authohaler):
100 micrograms/dose x 400 doses
(as sulfate)
Losartan 100 mg Tablet (as potassium salt) Salbutamol Resp. Soln. (for nebulization):
1 mg/mL, 2.5 mL unit dose (as sulfate)
Metformin Hydrochloride 500 mg Tablet (As Hydrochloride) Salbutamol Resp. Soln. (for nebulization):
5 mg/mL, 10 mL multidose (as sulfate)
Metformin Hydrochloride 850 mg Tablet (As hydrochloride) Salbutamol Resp. Soln. (for nebulization):
5 mg/mL, 20 mL multidose (as sulfate)
Metoprolol 50 mg Tablet (As Tartrate) Salbutamol (as Sulfate) + Inhalation: MDI
Ipratropium 21 micrograms ipratropium (as
bromide) + 120 micrograms
salbutamol x 200 doses x 10 mL
Nitrofurantoin 50 mg Capsule Salbutamol (as Sulfate) + Resp. Soln. (for nebulization):
Ipratropium 500 micrograms ipratropium (as
bromide anhydrous) + 2.5 mg
salbutamol (as base) x 2.5 mL (unit
dose)
Nitrofurantoin 100 mg Capsule Simvastatin 10 mg Tablet
Oral Rehydration Salts 20.5 g Sachet Simvastatin 20 mg Tablet
Paracetamol 300 mg tablet Simvastatin 40 mg Tablet
Paracetamol 500 mg tablet Simvastatin 80 mg Tablet
Paracetamol 120 mg (125 mg)/5 mL
syrup/suspension, 60 mL (alcohol-free)
Paracetamol 250 mg/5 mL syrup/suspension, 60 mL
(alcohol-free)
Paracetamol 100 mg/mL drops, 15 mL (alcohol-free)

Further, this institution shall not charge any fees directly from the referred patient but shall create the billing and payment
arrangement with RURAL HEALTH UNIT- TAAL for services provided.

This certification is being issued for PhilHealth accreditation and monitoring purposes.

CERTIFIED BY: CONCURRED BY:

Head/Owner Medical Director/Administrative Officer

Date Signed: Date Signed: