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PHIC Checklist for Tranche 1

The document outlines the reimbursement requirements for the Induction Phase of Acute Lymphocytic/Lymphoblastic Leukemia treatment under the Philippine Health Insurance Corporation. It includes a checklist of necessary documents and forms that must be submitted for reimbursement. The document also provides spaces for patient and member information, as well as signatures from the attending physician and parent/guardian.

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rjmanpowerservicesinc2022
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11 views

PHIC Checklist for Tranche 1

The document outlines the reimbursement requirements for the Induction Phase of Acute Lymphocytic/Lymphoblastic Leukemia treatment under the Philippine Health Insurance Corporation. It includes a checklist of necessary documents and forms that must be submitted for reimbursement. The document also provides spaces for patient and member information, as well as signatures from the attending physician and parent/guardian.

Uploaded by

rjmanpowerservicesinc2022
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Republic of the Philippines

PHILIPPINE HEALTH INSURANCE CORPORATION


Citystate Centre, 709 Shaw Boulevard, Pasig City
Call Call Center: (02) 8441-7442 | Trunkline: (02) 8441-7444
www.philhealth.gov.ph

Case No. _______________


Annex "E1 – ALL”
HEALTH CARE PROVIDER (HCP)

ADDRESS OF HCP

A. PATIENT 1. Last Name, First Name, Middle Name, Suffix SEX


¨ Male ¨ Female
2. PhilHealth ID Number cc - ccccccccc - c
B. MEMBER ¨ Same as patient (Answer the following only if the patient is a dependent)
1. Last Name, First Name, Middle Name, Suffix

2. PhilHealth ID Number cc - ccccccccc - c


DATE OF END OF INDUCTION PHASE (mm/dd/yyyy)

CHECKLIST OF REQUIREMENTS FOR REIMBURSEMENT (TRANCHE 1)


Acute Lymphocytic/Lymphoblastic Leukemia (Standard Risk)
Induction Phase

Requirements Please Check


1. Checklist of Requirements for Reimbursement (Tranche 1)
(Annex E1-ALL)
2. Photocopy of approved Pre –Authorization Checklist & Request
(Annex A-ALL)
3. Photocopy of completely accomplished ME FORM (Annex B)
4. Properly accomplished PhilHealth Claim Form (CF) 1 or PhilHealth Benefit
Eligibility Form (PBEF) and CF 2
5. Checklist of Mandatory and Other Services (Annex C1-ALL)
6. Photocopy of completed Z Satisfaction Questionnaire (Annex D)
DATE COMPLETED (mm/dd/yyyy):
DATE FILED (mm/dd/yyyy):

Certified correct by: Conforme by:

(Printed name and signature) (Printed name and signature)


Attending Physician Parent/Guardian
PhilHealth Date signed (mm/dd/yyyy)
Accreditation No.

Date signed (mm/dd/yyyy)

Revised as of November 2021 Page 1 of 1 of Annex E1 – ALL

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