li1 - Philippine Health Insurance Corporation

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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.
Page 1 and 2: Republic of the Philippines PHILIPP
Page 3 and 4: MCP[2 | iPhilHealth I Your Partner
Page 5: @fc^ PhilHealtn MBramier Your Partn
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)

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