li1 - Philippine Health Insurance Corporation

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'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
Page 1: Republic of the Philippines PHILIPP
Page 5 and 6: @fc^ PhilHealtn MBramier Your Partn
Page 7 and 8: GUIDELINES ON THE PROPER ACCOMPLISH
Page 9 and 10: Part V - Consent to Access Patient
Page 11 and 12: Note Check the box provided if offi
Page 13: theictusonthefirstminute-andfive(5)

li1 - Philippine Health Insurance Corporation

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