li1 - Philippine Health Insurance Corporation

Republic of the Philippines
PHILIPPINE HEALTH INSURANCE CORPORATION
Cilvslale Centre Building. 7(H> Shatv Blvd.. Pasig Cit\
PHILHEALTH CIRCULAR
N0./2. s.2010
TO:ALLACC
SUBJECT
ALL ACCREDITED HEALTH CARE PROVIDERS
(INSTITUTIONS AND PROFESSIONALS), ALL MEMBERS AND
EMPLOYERS, ALL PHILHEALTH OFFICES AND ALL OTHERS
CONCERNED
ENHANCED PHILHEALTH CLAIM FORMS
For operational efficiency and to reduce administrative cost for both the Corporation and its partner
stakeholders, the herein attached enhanced PbilHealth Claim Forms 1, 2 and 3 are issued. These
forms shall be used for ail types of claims to include confinements, packages and out-patient
services.
For veriiication purposes, National Tuberculosis Program (NTP) card are still required for all TB-
DOTS package claims. Providers are also advised to fill-out Part Tl of Claim Form 3 for Maternity
Care Package (MCP) claims.
In order to give ample time to prepare and consume old forms, these forms shall be used for all
types of reimbursements effective admission date September 1. 2010.
The new forms to include the guidelines on proper filling-out may be downloaded from the official
Corporate website (wNvvv.philhcalrh.gov.ph)
All issuances inconsistent hereof are hereby effectively repealed accordingly.
For strict Gonipliiince.
'

'PhilHealth
;:::i"i:-"::iii \btir }*urtitt;-r in Health,_, . _
L..-i:..i;:^{Claim Form)
""@@'"revised February 2010
IMPORTANT REMINDERS:
PLEASE WRITE IN CAPITAL LETTERS AND CHECK THE APPROPRIATE BOXES.
For local confinement, this form together with CF2 and other supporting documents should be filed within GO DAYS from dale of discharge.
For confinement abroad, this form together with other supporting documents should be filed within 180 DAYS from date of discharge.
Only one (I) original copy of this Form is required per claim application/availment.
All information required in this form are necessary and claim forms with incomplete information shall not be processed.
FALSE / INCORRECT INFORMATION OR MISREPRESENTATION SHALL BE SUBJECT TO CRIMINAL, CIVIL OR ADMINISTRATIVE LIABILITIES.
1. PhilHealth Identification No. (PIN):
3. Name of Member
PART I - MEMBER and PATIENT INFORMATION
(Member/Representative to Fill out all items with the assistance of (he Health Care Provider)
JI - I I I I I I I I I [-1I 2. Member Category:
T' -'orm may be reproduced and is NOT FOR SALE
CF1
[^Employed| | Sponsored
Drl,',"""@D0@
Last NameFirst Name
Middle Name(example Dela Cruz. Juan Jr., Sipag)r~||nd,viduallynufetime
1@'paying'@'
4. Mailing Address:
5. Date of Birth:
(House Number & Name of Street)
t)(Barangay)(Month)(Day)(Year)
(City/Municipality)
6.Contact Information (if available):
E-mail Address:
(Province)
Mobile No..
7.Name of Patient-
8 | | Patient is the Membei
Qpatient is a Dependent
Last Name
Middle Name (example: Dela Cruz, Juan Jr., Sipag)
I. CERTIFICATION OF MEMBER:f~' r"
/ hereby certify that the herein information (ire true and correct and may be used for any legal purpose.
Q ChildQ Parent
j [spouse
Signature Over Printed Name of Member
Signature Over Printed Name of Member's Representative 10.Relationship of the Representative to the Member'
I i I - LlJ - I i i i IDchili) [>arent
Date Signed (rnonlh-day-year)Dale Signed (rnonlh-day-year) Dale Signed (rnonlh-day-year) Date Signed (rnonlh-day-yea,)QSpouse[^Guardian / tatof
11 Reason for Signing on Behalf of the Member:
{^Member is Abroad / Out-of-Town[^Member is IncapacitatedQother Reasons:
PART II - EMPLOYER'S CERTIFICATION (for employed members only)
LPhilHealtfi Employer No (PEN):[
I I I I I 1 I 1-11 2. Contact No.:
3. Business Name and Official Address:
(Business Name of Employer)
(Building Number and Street Name)
{City / Municipality)(Province)(ZIP Code)
4. CERTIFICATION OF EMPLOYER-
This is to certify that all monthly premium contributions for and in behalf of the member, while employed in this company,
including the applicable three (3) monthly premium contributions within the past six (6) months period prior to the first day oj this
confinement, have been deducted/collected and remitted to PhilHealth, and that the information supplied by the member or his/her
representative on Part I are consistent with our available records.
_ Signalure_OxejPr[nled_HamspfEmployery_AuJhoNzedRep;esenjajive Official Capacity/DesignationDate Signed [mqnth-clay-yeafl_
(For PhilHealth use only)!

MCP[2 |
iPhilHealth
I Your Partner hi Hvuith
;:@@@.:@@ ::.@@(Claim Form)
IMPORTANT REMINDERS:
PLEASE WRITE IN CAPITAL LETTER5 AND CHECK THE APPROPRIATE BOXES
For local confinement, mis form together with CF1 and other supporting document should be filed within GO DAYS from date of discharge
FALSE / INCORRECT INFORMATION OR MISREPRESENTATION SHALL BE SUBJECT TO CRIMINAL, CIVIL OR ADMINISTRATIVE LIABILITIES
PART I - PROVIDER INFORMATION (Institutional Health Care Provider to fill out items 1 to 13)
This forn. ,,iay be reproduced and is NOT FOR SALE
si" I I I I I I I I I I I I I
(For PhilHe.lthu.* only)
CF2
3PhilHeallfi Accr-diialion No (PAN): I I I I I I I I I I-1. Calegoiy of Racilily
{hi-tiluiion-IHealU. Car. Provider)Q -_u /L3 rj ASC g RH(J
5PhHHeallh [dentificaticn No (PIHJ:|_LJ " I I I I I I I I I I " UQ S-L2 Q FDC Q TB DOTS
@1. Calegoiy of Facility
[] T-L-WL3 [] ASC[]RHU
J ~ I1? S-L2Q FDC[3TB DOTS
6MameofPaiieni@@@ ~7^7^_^7
n p-li n mcp n ______
Lasl NameFirsl NameMiddle Name (example Dela Cruz. Juan Jr.. Sipag}
7 DateofBirih I t I ~ 1 i 1 ~ | i i i | 8 Age || Year/s [] Month/s [] Day/s [] 9. Sex [] Male [] Fern
10. Confinement Period
(monlh-day-ycar)
a. Dale Admitted ! i I - |_|_J - | ii @ |b Time Admitted ]___J AM |j PMe Mo of Days Claimed ||
.DaleAdi nilled Iil-lil-liii1
bTimeAdmitted]___
|AM
(monlh-djy-year) (monlh-djy-year)
c. Date Discharged [_jj - |_jj - | ,, , |d Time Discli^rgerJ-1| AM || PMf In c^Ge of Dealh, |_J - [_jj - |_j_
.DateDis charged LJ-LJ-LllJ
|AM
(month-day-year) (mcnlh-day-year)specify date(nionlli-day-year)
11.HeotlhCareProviderServices
aRoomandBoardPrivate|IWardII
ActualCharges
PhilHealthBenefit
FarPliilHeatihUedOn^
(Adjustments/Remarks)
b.DrugsandMedicines(PartIIfordetails)
cX-ray/Lab/SuppliesOthers(Par!IIIlorstalls)
dOperatingRoomFee
TOTAL
eBenefitPackage
12 Case Type' Qa Qb Qjc Qd13 ComplelelCD-10 Code/5
"This is only applicable lor claims with fee for service paymenl mechanism
(Professional Health Cat s to rill out items 14 to 16 )
1'1AdmissionDiagnosis
15CompleteFinalDiagnosis
16 Professional fees I Charges
a.NameofProfessional
bPhilHeallhAccreditationMo
cNumberofVisili/RVSCode
clInclusiveDates(mmdj-m-y)
o.ToIjIActual
PFChargGs
I.PhilHeallh
Benefit
bymembeii
hSignature
DateSigned
Only
1111l-lhi1
1111l-l111111l-l1
1,,,hil-l1
1,1,1-1hi1

Generic/Brandname
(dose/crip/syrup/injeclililo
Wbv.Slin,'Jn\'}li;mcontcr.l)
Qty
UnitPrice
Actual
Charges
Benefit
TOTAL
PARTIII-X-RAY,LABORATORIES,SUPPLIESANDOTHERS(useadditionalsheetifnecessary)
Particulars
Qty
UnitPrice
Actual
Charges
PhilHealth
Benefit
A.X-Ray(Imaging)
B.Laboratories/Diagnostics
CSuppliesandOthers
? Official receipts for drugs and medicines / supplies purchased by member from external sources as well as laboratory procedures done outbide the
hospital which are necessary for the confinement tie merit are attached are attached to this to this claim. claim.
PART IV - CERTIFICATION OF INSTITUTIONAL HEALTH CARE PROVIDER
I certify that sendees rendered were recorded in the patient's chart and hospital, records and that the herein information given are (rue and correct.
TOTAL
The foregoing items and charges are in compliance with the applicable laws, rules and regulations.
Signature Signature Over Printed Over Name Printed of Authorized Name Representative of Authorized RepresentativeOfficial Capacity / DesignationDate Signed Official {month-day-year)
Capacity/ Designation
II _ II _ II
PART V - CONSENT TO ACCESS PATIENT RECORD/S
I hereby consent to the examination by PhilHealth of the patient's medical records for the sole purpose of verifying the veracity of this claim
I hereby hold PhilHealth or any of its officers, employees and/or representatives free from any and all liabilities relative to the herein-mentioned
consent which I have voluntarily and willingly given in connection with this claim for reimbursement before PhilHealth.
Signature Over Printed Name of Patient
jJ - UJ - U^J
Dale Signed (month-day-year)
ignature Over Printed Name of Patient's Representative
Date Signed (month-day-year)
Reason for Signing on Behalf of the Patent
Q Patient is IncapacitatedQ Other Reasons:
Relationship of the Representative to the Patient
j~| Spcuse r~] Child f~~j Parent r~j Guardian/

@fc^
PhilHealtn
MBramier Your Partner in in Health tieaun(Claim Form)
*SPrevised February 2010
IMPORTANT REMINDERS:
THIS FORM SHOULO BE FILED TOGETHER WITH PHILHEALTH CLAIM FORMS 1 AMD 2 WITHIN GO CALENDAR DAYS FROM OATE OF DISCHARGE
FOR LEVEL 1 FACILITY, THIS FORM SHALL BE REQUIRED FOR ALL BENEFIT CLf.lMS
FOR LEVELS 2, 3 AND A FACILITIES, THIS FORM IS REQUIRED IN CASES OF I) EMERGENCY/TRANSFERRED 2) LESS THAN 24 HOURS ADMISSION 3) CASE TYPE 'D' DIAGNOSIS
THIS FORM SHALL BE REQUIRED FOR ALL CLAIMS ON MATERNITY CARE PACKAGE.
1 PhilHealth Accreditation No (PAN) - Institutional Health Care Provider:I I 1 I I I I I I |
PART I - PATIENT'S CLINICAL RECORD
2. Name of Patient|7~Z. 1
Thr Wrn may be reproduced and is NOT FOR SALE
CF3
Last Name,
(example. Dela Cruz, Juan Jr, Sipag)
4 Date Admitted
Time Admitted. | |AM j |p
5. Date Discharged'
Time Discharged
I AML|PM
hh-mm
6 Brief History of Present Illness / OB History
7. Physical Examination ( Pertinent Findings per System )
General Survey:
Temperature1
Abdomen
HEENT
Chest/Lungs
GU(IE )
Skin/Extremities
CVS:
NeuroExaminalion
8. Course in the Wards (attach additional sheets if necessary).
9 Perhnenl Laboratory and Diagnostic Findings ( CBC, Ufinalysis, Fecalysis, X-ray, Biopsy, etc )
10 Disposition on Discharge: Q Improved\J Transferred\J HAMA\J Absconded Q Eipired

T
-*RT II- MATERNITY CARE PACKAGE
PRENATAL CONSULTATION
1.Initial Prenatal Consultationi i I ~ I
2.Clinical History and Physical Examination
a.Vital Vital signs signs are are normalQc. normal[_ Menstrual History LMP |_j_| - | | | - j , , ,
MonthDayYen
Age of Menarche _
3. Obstetric risk factors
a Multiple pregnancy Qd Placenia pieviaQg Hislory of pie-eclampsia Q
b Ovarian cyslj~~|13. Hislory c( 3 miscarriages Q]h Hislofy of eclampsia Q
c. Myoma ulenr~jf History of stillbiifh|~~|i Premature conlraction f~
g Hislory of pie-eclampsia Fl
h Hislory of eclampsia Fl
i Premature conlraction f~\
4 Medical/Surgical risk factors
bHearlDisease
c.Diabeles
?
?
d
e.
f.
ThyroidDisorder
Obesity
Moderatetosevere
?
gEpilepsy
hRenaldisease
i.Bleedingdisorders
?
a
k. Hislory of uterine myomectomy Fl
5.AdmittingDiagnosis
6.DeliveryPlan
a. Orientation to MCP/Availment of Benefits
? ?
b. Expected date of delivery |_j_J - [ , | - [
@Won HiDay
7. Follow-up Prenatal Consultation
a Prenatal Consultation No. | 2nd | | 3rd | | 4th [ | 5th | } Cth | [ 7ih | j 8ih | | 9ih | | 10th | | 11th j | 12th |
b.Date of visit (mnvdn^ I I I I ! I I I
c.AOG in weeks
d.Weight & Vital signs.
d1 Weight
d.2 Cardiac Rale
d 3 Respiratory Rats
d.4 Blood Pressure
d 5 Temperature
?
DELIVERY OUTCOME
8. Date and Time of DeliveryDate [__j_J - |_jj - | , , , |Time ||flu ||ra
AfnnffiDsyVesthh-nunIih-mm
9 Maternal Outcome: Pregnancy Uterine,
10. Birth Outcome:
11.Scheduled Poslpartum follow-up consultation 1 week after delivery
12.Date and Time of DischargeDate | , | - | , | - ] @ ,
MonthDayYear
POSTPARTUM CARE
I I hi ! 1-1 I ! I 1
MonlhDayyear
Time ||am |U
hh-iwnhh-ntm
13.Perinea! wound careQ
14.Signs of Maternal Postpartum ComplicationsQ
15.Counselling and Education
a. Breastfeeding and Nutrition[_]
b Family Planning[_J
16.Provided family planning service (o patient (as requested by paiieni)[J
17.Referred to partner physician for Voluntary Surgical Sterilization (as requested by pi)Q
18.Schedule the next postpartum follow-up\^\
done
19 CertificationofAttendingPhysician/Midwife'
Icertifythat/heaboveinformationgiveninthisfan
(art:trueandcorrect
SignatureOverPrinledNameofAttendingPhysician/Midwife
Dale Signed(Maul /Day/Year)

GUIDELINES ON THE PROPER
ACCOMPLISHMENT OF REVISED PHILHEALTH
CLAIM FORMS 1, 2, & 3
I. General Guidelines applicable lo all Claim Forms:
1.Claim Form 1 (CF1) -and Claim Foim 2 (CF2) shall be
acecimpbshed and submitted for ALL claim applications
except for confinement abiond.
2.All CF shall be accomplished using capital letteis and by
checking the appropriate boxes All items should be
marked legibly by using ballpen or sign pen only.
3.Names should be written starting with hist, first and
middle name and should be separated by a comma.
Extensions such as (but not limited to the following)
jr., Sr., III should be indicated after die first name.
Part II - Employer's Certification
(for employed members' only)
provides ihe basic information nbout the employer nnd
contiiiii:; the ccrtiEcndon oi qualifying contributions and
correctness of the informfition supplied by the member
The tables below explain die proper way of accomplislirng
CF1.
Part I - Member and Patient Information (Member/
Representative to fill out items 1 to 11)
Item
No.
DescriptionandInstruction
Illustration:
DELA CRUZ, JUAN JR.,SIPAG
Last nameFirst Name Middh Name
4.All dates should be filled out following tins format
MONTH-DAY-YEAR (MM-DD-YYYY).
Illustration:
July 27, 2010 should he written as 07/27/2030
5 Time should be filled out using this format: HOUR
MINUTE (HH:MM) following die 12-hour convention. It
should be indicated in die appropriate box whether AM
(morning) oi PM (afternoon and evening).
I Has t ration:
Nine fifteen in the morning should be written as 09:15 A A/
6. PhilHeakh Identification No. (PTN) and PliilHeali.li
Employer No (PEN) should be filled oul
following die 2-c'-l format
Wnstnitior.: 12-123456789-1
7 PbiLHealth Accreditation No (PAN) for institutions and
professionals should be filled out following the presenbed
formats
Illustration jor@institutions.
Hospitals -H12345678, ASC-A12345678, MCP-M12345,
TBDOTS- T12345 and FDC- D12345
Illustration for professionals: 1234-1254567-1
8. For local confinement, supporting documents together
with CF1 and CF2 should be filed with PhilHealth witliin
60 days horn date of discharge, e g.,1
II. Specific Guidelines:
@Member Data Record
@MI5 (for individually paying members')
@PliilHeallh ID (foi OF\V, Lifetime Member and
Sponsoie.d Progrjm Ml-itiLvi)
A. Chirm Form 1 (CF1)
CFl is divided into two paits-
Part I - Member and Patient Infoimatioii requnes
rnfoiination about the membei and patient TO ascertain the
identity of die member/patient/dependent for eligibility to
PhilHealth benefits
1
2
3
4
5
6
ncasediePINisnotknown,thcmemberisad\nsed
o
Inquirefrom.myPliilHealthoffice;or
j.Seekinformationfromemployer(foremployed
members)
Checktheappropriateboxfordiecurrentmembership
categorywhether:
employed(goveinment/pnvate),IndividuallyPaying;
Sponsored:OFW&Lifetime.
Incasethenameisdifferentfromwhatisregistered
withPhiLHealth(perMDR}themembeiisadvisedto
attachsupportingdocuments(birthcertificateor
marriagecontiact;isapplicable)forupdaungofMDR.
ft'hisistheaddresswheretheBenefitPaymentNoticepiPN]
willbemailedto)
Writethecompleteaddressofdiemember,indicating
thehousenumber,nameofstreet,bamngay,
municipalityorcity,provinceandzipcode.
Writediedateofbirdiofmemberfollowingdie
piescnbedLormutfordate.
Writethemember'scontactinformationsuchasemail
address,mobilenumberandkmdlinenumber,if
available.

Name of Patient
Write the complete name of the patient starting wirh
last. Erst ::nd middle name. It should be separated by :i
comma Extensions such as (but not limited to tine
following) ]r., Sr., IJJ should be indicated after the Eisc
Patient is the Member
If patient is Llic member, check [he appiapime box and
chen proceL'd to itc-m 9
Patient is a Dependent
If pauent is a dependent (to be filled out if patient is
dependent)
Check the appropiuUe box if patient is :i child, spouse or
parent of the member.
Reminder
If piiticnt is ky;d JeptndenL uf the member, the patient's
name should appeal in the MDIt If not, attach
applicable suppoiting documents as proof of
dependency
Certification of Member
Signature over printed name of member
The membei -affixes his/hci signature over printed
name ceitih'ing tliat all information suppbed m Part I
are true and cotrecr and granting consent 10
PhilHealth to use die supplied information for any
legal purpose.
In case die member is a niinoi 01 a survivor-child, a
representative (legal guardian) will also counteisign
using the membei representative portion. If die legal
guaidian is not duly indicated in die JNIDR, a copy of u
judicial oider shall be attached to die claim.
Date signed
The membei indicates the date when be/she signed
die certificate following die prescribed format for date
Signature overprinted name of member's
representative
' An audiorized representative of die member may sign
on lus/her btlv.ilf.
Date signed
The audiorized representaove of die pciueni; indicates
the date when he/she signed on behalf of the patient
following the prescribed form.it foi date.
Relationship of the Representative to the member
Check die appropriate box whether die representative
of the member is Ins/her cliild (must be 1 S years old
:md above), spouse, paienl and guardian/next nf kin
Reason for signing on behalf of the member
Indicate the reuson for signing on behalf ol" (.he
membei such as: PI) Member is Abroad /
Out-of-Towu; (2) Member is incapacitated and
l'3) Other reasons F

Part V - Consent to Access Patient Records
Tins contains the consent voluntarily given by the patient lor
verification of the veracity of information relative to the
evaluation and reimbursement of the claim.
The following tables below explain the proper way of
accomplishing CF2:
Part I - HEALTH CARE PROVIDER INFORMATION
Institutional Health Care Provider to fill our items
1 to 13
No.
1
2
3
4
DescriptionandInstruction
NameofFacility
Writethecompletenameoffacilityincapitalletters
asindicatedhidieaccreditationcertificate.
Writediecompleteaddressofthefacility.
e.g.,HospitalA,aternaryhospitalcategorizedas
accreditedhospitalandTBDOTSfacility,claiming
forTB-DOTSpackage,diePANforTB-DOTS
facilityshouldbewritten.
CategoryofFacility
Checkdieappiopnateboxfordiecategoryofdie
facilitywhether:
@Tertiary-L4/L3fT-L4/L3)
@Secondary-Level?(S-L2)
@Pnniaiy-Level1fP-LlJ
@AmbulatoiySurgicalClinic(ASC)
@FreestandingDialysisClime(FDC)
@MaternityCarePackageprovidei(MCP)
@RuralHealthUnit(RHU)
@TBDOTS
@Otliers(fornon-accieditedfacility)
Ifthefacilityhasmultipleaccreditations,e.g.,
accreditedhospitalandTBDOTSfacility,accredited
RHUandTBDOTSfacility,accreditedRHU,TB
DOTSfacilityandMCP(3miaccreditation),check
theappropriateboxapplicabletodiebenefitclaim
10
Oa.lOh
0c,10d
Age
WiiLt; die ;ige of the patient at the time of admission
and check appropriate box whether the age is in
year/s, month/s or day/s
"heck appropriate box whether patient is male or
Confinement Period
Date Admitted. Tune Admitted;
Date Discharged. Time Discharged
Write the confinement pei:iod to include the date and
time of admission and discharge following the
piescnbed formats lor date and time.
ForTB-DOTS Package:
@For patient on intensive phase, indicate die
Registration Date as date admitted (item 10a)
following die prescribed format for date.
@For patient on maintenance phase, indicate die
Start Date of maintenance phase as date
admitted (item 10a) following the prescribed
format far date.
@Write NA (Not Applicable) in time admitted,
date and time discharged.
For Outpatient Malaria Package:
@Date admitted corresponds to die date of the
start of tieatment.
@Date discharged corresponds to die date of
the last day of treatment.
@"Write NA ('Not Applicable) in time admitted
and time discharged.
No. of Days Claimed
Write die number of days claimed. In computing the
number of days claimed exclude the day of
admission and include the day of discharge.
Illniiration:
For in-patient cases:
Admission Date: January 1, 2010
Discharge Date: January 13, 2010
No of Days Claimed: 12 Days
For Qut-pAllent cases:
Admission Date: January 7, 2010
Discharge Date: January 7, 2010
No. of Days Churned. 1
In case of death, specify date
In c:ise of death of patient during confinement
penod, specirv the dnte of death in the appropriate
box following die prescribed foimut for date
5
6
Member'sPhilHealthIdentificationNo.(PIN)
(formember)
WritetheMember'sPhilHealthIdentification
Number(PIN)followingthe2-9-1form,it
NameofPatient
Writediecompletenameofthepatientstartingwith
last,Cistandmiddlename.Itshouldbeseparatedby
acomnu.Extensionssuchas(butnotlimitedtothe
following)Jr.,Sr.,IIIshouldbeindicatedaftcidie
firstname.
"CC7ntethedate,ofbirthofpatientfollowingthe
prescribedformat
Health Care Provider Services
Indicate die amount of the following items
accordingly:
@"Actual charges" refeis ro the total amount
charged by the health caie provider (HCP) for
every benefit item.
@"PhilHenlth benefit" refers to the amount that
will be reimbursed to the HCP by PhilHtaltli.
The s.ime represents deduction made from
die pa dent's actual chaige as member's
benefit.
For item lla Room and Board, check Appropriate
box whether private or ward.

@Private - refers to a single occupancy room or
with less than thi.ee beds per room divided by
either a peimrmeni: or se nil-permanent
partition.
@Wmd - icfe-rs to a room with Uiiec 01 moic
beds.
For benefit packages not requiring ilcmiz,iuon PHIC
benefit should be indicated in lie.
Case Type
Check the appropriate box of the coirccr illness case
type whether A,B,C or D Tins is only applicable for
claims with fce-for-service payment mechanism.
Complete ICD-10 Codes
Write die complete ICD 10 code/sof the p-.iuent's
diagnosis. The fust code indicated should be the
piimaiy illness. The succeeding codes shall represent
co-morbidities.
Professional Health Care Provider to fill out items 14 to 16
16
lfia,
161)
16c,
16d
Admission Diagnosis
W'nte die admission diagnosis.
Complete Final Diagnosis
Write the complete final diagnosis of p;iuenfs
illness/injuries including the mam diagnosis ;md
other co-morbidities.
Provide the following information, as applicable::
u The cuologic agent ( e.g;, Escheiichia coli) in
diagnosing infections,
b For benign und malignant tumors, indicate the.
site, moiphology and behavioui.
c.In diagnosing injuries, provide the nature of
die injury, and it possible, the place of
occuncnce and die activity- of die one injured
during die tune of the incident
d.When diagnosing poisoning or advei.se
reaction cases, specify die offending agent
(e.g., drug, chemical).
e.Specify if a condition is a late effect or
sequelae of anodiei condition (e g , pubnonaiy
Tibrosis sequelae of PTB).
For mulaplc conditions, the main oi" primuLy condiuon
must be the Gist diagnosis ihfit should be written
e.g., Patient X is diagnosed with acucc pyelonephritis
with concomitant hypertension and diabetes
Complete Fin.il Diagnosis: acurc bacterial pi,-clonephriDb,
hvpeiiension contioOed, diabetes mclliwr, cono-olled
Professional Fees/Charges
Name of Accredited Professional and
PhilHealth Accreditation No.
Write the nnmc/s of pro regional health care
provider/s who attended and provided services to die
patient with corresponding PluIHealdi
accieditation nmnber/s in the boxes provided.
No. of Visits/ RVS Code and
Inclusive Dates
Indicate die following services rendered to the
patient by die professional
Medical C;ise -
@Indiciite it daily visits with inclusive daiey
@Indicate lrpreopcranve mpadeni consultation
(CP Clearance) inclusive dates
16f
16g
16h/l
Surgical c.isc -
@Indicate die appropriate RVS code rind date
of opeiLition/procedure.
@Anesthesia sendees - Indicate the type of
anesthesia sendees given and date of service/
procedure.
Professional Health Care Services Indicate the
amount of the following items accordingly:
@"Total ..Actual Piofessional Fee Charges'1 refcis
to the total amount of die professional fee
chaigc-d by die health care professional to the
patient before deduction of PhilHealth
Benefit.
@"PhilHealth benefit1' refers to the amount that
will be reimbursed to the professional by
PhrlHealth. The same represents deduction
made from die patient's actual charge as
member's benefit.
@"Amount paid by member" refers to die
payment made by die member after deduction
of PhilHealth benefit This represents die
excess amount shouldered by die member. Tf
full payment was made, indicate the amount
equivalent to actual professional charges.
Signature/Date Signed -
@The professional who actually rendered die
services shall sign in the box provided and
indicate the date of signing following die
pLCSdibed format for date.
Part II - Drugs and Medicines
List down dings and medicines used/consumed during
confinement
@Indicate the generic mime and the corresponding brand
name ot die drug
Illustration: amoxicillin (Amoxil);
@Indicate coiresponding preparation (dose,cap/tab in
mg; syrup/suspension in mg/ml; amp/vial in nag/ml);
@Indicate total quantity used (piece, ampule, vial, etc);
@Indicate the amount per unit;
@"Actual charges" refers to the actual amount charged by
die facil.it}' for ever)- item.
@"PhilHealth benefit" refers to the total amount of
benefits foi all drug? and medicines
@Indicate the total -amount of actual charges and
PliilHealth Benefits for all drugs and medicines
@Foi benefit packages not requiring iiemizanon, only die
totnl amount of PHIC benefit should be indicated.
Part III - X-ray, Laboratories, Supplies and Others
Indicate all diagnostic procedures [imaging, laboratory tests,
etc.) done and supplies and other items used during
confinement
@Indicate total number of procedures/items.
@Indicate the amount per item;
@'"Actual charges" refers to the total amount charged by
die facility foi ever";' item or service rendered;
@"PhilHealth benefit" rcfeis 10 the total amount of
"benefits foi x-ray, laboratories, supplies and others.
@Indicate die total amount far columns Actual Chaiges
and FhilHejilth Benefit

Note Check the box provided if official receipts foi
drugs find medicines/supplies purchased by member from
external sotuces us well as laboratory procedui.es done
outside the hospital which are necessary for die
confinement, are attached to tlie ckim.
Part IV- Certification of Institutional Health Care
Provider
Signature over Printed Name of Authorized
Representative
The authorized representative shall write his/he: printed name
and aftix his/her signature certifying th.\t the services rendered
were recorded in the patient's chart and hospital records and the
given information given are true and correct.
Official capacity/Designation
Write the official capacity/designation of the signatory
Date signed
Write die date of signing following the prescribed foimat
for date.
Part V - Consent to Access Patient Records
Signature over Printed Name
The patient shall write his/her name and affix his/hei
signature signifying consent to PlnlHcnlth's verification of die
veracity of die information contained in die claim.
Date Signed
Write the date of signing following the prescribed format for
date.
Part II Maternity Care Package
Tins provides the inform a lion fib our die prenatal consultation,
delivery outcome and postpaitum care of the patient.
CF3 is not requiic-d in other PhilHealth benefit packages such
as Newborn Caie Package. Voluntary Surgical Contraception.
Outpatient Malaria and TB-DOTS, regardless of facility level.
The tables helow explain the propei wax of accomplishing
CF3:
Part I Patient's Clinical Record
No.
1
2
Description/Procedure
PhilHealthAccreditationNumber(PAN)
Tinsreferstothecurrentaccreditationmirabeiof
theinstitutionalhealthcareproviderassignedby
PhilHcalth.
Formultipleaccreditation,indicatetheaccreditation
numberofthefacilityapplicabletothebenefit
claim.
WritePANfollowingtheprescribedformat.
Vntediecompletenameofthepatientstartingwith
ast,firstandmiddlename.Itshouldbeseparatedby
comma.Extensionssuchas(butnotlimitedtothe
ollownigj]r.,Si.,Hishouldbeindicatedafterthe
firstname.
Signature Over Printed Name of Patient's Representative
The authorized represents!five of the patient may sign on
behalf ot the patient.
Date Signed
Write die date of signing following the prescribed format for
date.
Relationship of the Representative to the Patient
Write die relationship of die leprescntarive to the patient by
checking the appropriate box whether spouse, child tor
majority age, paient or guaidian/next ot kin.
Reason for Signing on Behalf of the Patient
Indicate the reason for signing on behalf of die patient
whether patient is incapacitated or due to othei reasons
(specify).
C. Claim Form 3 (CF3) (To be filled out by accredited
Health Care Provider)
Tins cl.iim form will support the information supplied tn the
Claim Foim 2 and shall be used in die evaluation of proper
case type determination especially type D cases, emergency
cases snd less than 2-1 hour admissions
This ij. mandatory m:
@Level 1 facilities,
@Case type D;
@Maternity Care Package,
@" Emeigency/ Transferred cases, and
@Less than 24-hour confinement
Part I - Patient's Clinical Record
This is die basis of PhilHcalth to ascertain die patient's clinical
liistory, pertinent physical examination findings, laboratory &;
diagnostic findings and disposition upon discharge.
3
4
5
(i
7
8.
ndicatepatienL'schiefcomplaintforseeking
consultationand/orreasonforadmission.
followingtheprescribedformatfortime.
Indicatethetimewhenthepatientwasdischarged
followingtheprescribedformatfoitime.
Indicatethechronologicaleventsofpresentillness
includingallsignsandsymptoms,prompting
consultationandsubsequentconfinementas
describedbythepatient/guardian/informant.
Indicatetheobjectivefindingsincludingpertinent
negativefindingsperorgansystemelicitedduringdie
conductofdiephysicalexamination.
Indicatesignificantchanges/progressonthepatient's
conditionduringconfinement.Mayaddadditional
sheetsifnecessary
Indicateallsignificantlaboratoryresultsand
diagnosticfindings.

2)
10
D
C
w
T
spos
eckt
lethei
,mstc
tioi
lea
the
@red
onDischarge
ipropnaccboxfoi
pauenrwnsdischn
HomeAgainstM
(KAMA),AbscondedorExpired
diedisposition
rgedImproved,
-dicalAdvice
gEpilepsy
hRenaldisease
iBleedingdisorders
1Historyofpreviouscaesanansection
kHistoryofuterinemyomectomv
Part II Maternity Cart Package (MCP)
CF3 Part II shall be accomplished for MCP claims and
must be submitted together with CF1 and CF2.
5
AdmittingDiagnosis
Writetheadmittingdiagnosisofdiepatient
Item
No.
Description/ Procedure
PRENATAL
Initial Prenatal Consultation
Wine the- date of the initial prenatal consultation of
tilt patient following die prescribed format fot dace.
Clinical History and Physical Examination
Vita) si^tis ate normal
Check die box provided if die vital signs of the
patient '.ire normal.
(ib
Writetheexpecteddaleofdeliveryfollowingthe
prescribediormatfordate.
Ascertain the present pregnancy is low risk-
Check die box provided if present pregnancy is low
nsk
Menstrual History
Indicate die dale of Last Menstrual Peiiod (LMP)
following die prescribed format toi date and Age of
Menarche.
Obstetric History
Write the Obstetric Seme of die patient by indicating
die number of pregir.tncy./pregnancies (G) and the
number of piegnancy/pregnancies Unit reached
vi.ibilin' (P) The next four (4) blanks correspond to
pregnancy outcome (Terr/i, Pralerm. .Abortion and
Uvmg)
lUitsirdtiQii A mother on hei duid pregnancy has had
2 deliveries to m-o (2) Live, term offspring widi no
hisiory of nboiiion.
The obstetric score shall be
7c
7d
Writedieweightandvitalsignssuchaycardi-aclate,
respnaiorvrate,bloodpressureandtemperature
conespondingtotheconsultation.
DELIVERYOUTCOME
Obstetric Risk Factors
8
WntediedateandtimeotdeliverytoUowmgdie
ptesciibedformatfoidateandlime.
Check die appropriate box it patient has any of the
following obstetric risk factors:
a.Multiple pmgn.incy
b.Ovauiiui cyst
c Myoma uixn
d. Placenta pic via
e Histoiy of 3 rmscamages
1". Histoiy oi stiHbirLJi
g. Mistoiy of pre-eclampsm
h Histoiy of eclampsia
1 Premature contraction
9
Wnlediematernaloutcomeasto.
@ObstetricIndex-IndicatetheObstetricIndex
eg.,G3P3(3003)
@AOGbyLMP-IndicatetheAgeofGestation
(AOG)mweeksbasedondieLastMenstrual
Peiiod(LMP).
@MannerofDelivery@Indicatediemannerof
dekvery(NSD,assisted)
@Presentation-Indicatethepresentationofdie
fetus(cephalic,lueech,compound)
Medical/ Surgical Risk Factors
Check the appropriate box if p:iUcj.K has
following mtdicdt/sui-giciil us!: faciors.
a.Hypertension
b.Heine Disease
c.Diabetes
d.Thyroid disorder
e Obesitjf
Moderate- to Severe Asthma
of die
10
BirthOutcome
WntethebhthoutcomeoitheIcaisasto
@FetalOutcome@Indicatewhetlieithefetus
isalive("live")ornotsuchas"fetaldeath"or
"sullbudi".
@Sex@Indicateihcsexoithefetuswnctlier
femaleormale
@Birthweight-Indicatethebirdiweightof
feiuiingrams

theictusonthefirstminute-andfive(5)
minutesthereafterasroAppealand.-.Pulse,
Gnmace,ActivityandRespiration.
11
ScheduledPostpartumfollow-upcoiisultarion
1weeknfterdelivery
Writetliescheduledpostp.imimandnewborncare
follow-upconsultationfollowingdieprescribed
formatfordate.
12
Writethedateandtime,whenpauenrwnsdischarged
followingtheprescribedformatsfor.dateandtime.
POSTPARTUMCARE
13
14
15
15a,15b
Perinealwoundcare
Checktheboxprovidedifperinea!woundeaiewas
done.Writesignificantfindings,ifany,indiemnai'ks.
Checktheboxforanvsignofmaternalpostpartum
complicationsWutesignificantEndings,ifany.iji
tlieicm.irks.
BreastfeedingandNutrition;FamilyPlanning
Checktheboxitcounsellingandeducationwas
piovidedtotliepatientonBreastfeedingand
NutritionandFamilyPlanningUseremarksportion,
ifany-
16
17
Checktheboxiffamilyplanningservicewas
providedtothepatientasrequested.Useremarks
portion,ifany.
ReferredtopartnerphysicianforVoluntary
SurgicalSterilization(asrequestedbypatient)
Checkdieboxifpatientwasreterredtopartner
physicianforvoluntarysurgicalsterilizationas
requested.Useremarksportion,ifany.
IS
Checktheboxifpatientwasscheduledforthenext
postpartumfollow-upUseremarksportion,ifany.
19
Writethedateofsigningfollowingtheprescribed
foimatfordate.