This form may be reproduced and

CSF
Republic of the Philippines is NOT FOR S ALE
PHIL IPPINE HEA L TH INSURA NCE CORPORA TION
Citystate Centre 709 Shaw Boulevard, Pasig City
`P hilHealth
Year Partner in Heal!h
Cal l Cent er ( 02) 441- 7442 • Tr unkl i ne( 02) 441- 7444
www.philhealth.gov.ph (C laim S ignature F orm)
email: actioncenterWphilhealth.gov.ph
R evised S eptember 2018

IMPOR TANT R E MINDE R S : S eries 8

PLE AS E WR ITE IN CAPITAL LE TTE R S AND C HE C K THE APPR OPR IATE BOXE S .
All information required in this form are necessary. C laim forms with incomplete information shall not be processed.
F ALS E /INC OR R E C T INF OR MATION OR MIS R E PR E S E NTATION S HALL BE S UBJ E C T TO C R IMINAL, C IVIL OR ADMINIS TR ATIVE LIABILITIE S .

PAR T I - ME MBE R AND PATIE NT INF OR MATION AND C E R TIF IC ATION

1. PhilHealth Identification Number (PIN) of Member:
l 112 7 V~
2. Name pf Member: ` 3. Member Date of Birth:
71,c4 -'z r

Last Name F irst Name Name E xtension

IiP/S R /III)
Middle Name
lee DELA CRUZ J UAN J R SIPAG)
one day
/ F1-

4. PhilHealth Identification Number (PIN) of Dependent: -

LI
5. Name of atient 6. R elationship to Member:
t 4 CgfR4V 'i- n child parent n spouse
L ast Name F irst Name Name E xtension Middle Name
lie/S R /III) lea: DELA CRUZ J UAN J R SIPAG)

7. C onfinement Period: 8. Patient Date of Birth:

a. Date Admitted: Cg
month day
9. C E R TIF IC ATION OF M,gMBE
(J r/n
year
v 1 b. Date Discharged: U~
mont h
r4 .J
day
-
year month
_
dajf
' IV
ye1
-t 1M
Unde

S ignature Over Printed Name of Member

j&j TY -
fty df law, pattest thdt the rnforma ra o rded in this Form are true and accurate to the best of mY knowled9e.
P~

S ignature Over Printed Name of Member's R epresentative

Date S igned
mont
nt h
X day '
-N 1
year
Date S igned
month
-
day year
If member/representative is unable to write, R elationship of the S pouse C hild Parent
put right thumbmark. Member/R epresentative representative to the member S ibling Others, S pecify
should be assisted by an HC I representative.
C he the appropriate box

LI
R eason for signing on Member is incapacitated
Member C R epresentative
behalf of the member Other reasons:

PAR T II- E MPLOY E R 'S C E R TIF IC ATION

1.PhilHealthE mployerNumber(PE N): (fl I D 0 - d pb 2 0 -f 2.C ontactNo.:
3. Business Name:
Business Name of E mployer
4. C E R TIF IC ATION OF E MPLOY E R :
"This is to certify that the required3/6 monthly premium contributions plus at least 6 months contributions preceding the3 months qualifying contributions within12
month period prior to the first day of confinement (sufficient regularity) have been regularly remitted to PhilHealth. Moreover, the information supplied by the member or
his/her representative on Parllore consistent with our available records."
Date S igned
S ignature Over Printed Name of E mployer/Authorized R epresentative Official C apacity/Designation month day year

PAR T III - C ONS E NT TO AC C E S S PATIE NT R E C OR D/S

thereby consent to the submission and examination of the patient's pertinent medical records for the purpose of verifying the veracity of this claim to effect efficient
processing ofbenefitpayment.
thereby hold PhA Heafth or ani{ o4res pfhrpers j loyees w a~iytssifree from any legal liabilities relative to the herein-mentioned consent which! have
voluntarily and willingly given h'nbrfhectfon with this claim tar ement before PhilHealth.
f ~ ~~cl
reimbu'r~}

S ignature Over Printed Name of Member

I , /" flrf r Date S igned ra I
month day' year
If member/representative is unable to write, R elationship of the n S pouse n C hild Parent
put right thumbmark. Member/R epresentative
should be assisted by an HC I representative.
C heck the appropriate box.
representative to the patient S ibling
I IOthers, S pecify

n
R eason for signing on I Patient is incapacitated
Patient n R epresentative
behalf of the patient P Ot her r c as ons :
PAR T IV - HE ALTH C AR E PR OF E S S IONAL INF OR MATION
Accreditation No. Date S igned
S igna/I eOver Printed Name month day year
Accreditation No. 1llup - -~5 fig0$5 4
C HAR M yatPu'te~ It i ~eMD•J MS PH
ed 6
month day
Y~
year
Accreditation No. Date S igned
S ignature Over Printed Name month day year

PAR T V - PR OVIDE R INF OR MATION AND C E R TIF IC ATION

1.PhilHeatth Benefits: IC D10orR V S C ode: 1. F irst C ase R ate 2. S econd C ase R ate
I certify that servi re ere recordedin the patient's chart andhealth care institution records and that the herein information given are true and correct.
MA. S E r A . HIZOLA Acting Administrative Officer Date signed - flu
S ignature Over Printed Name of Authorized HCI Representative Official Capacity/Designation mon h day year