PMRF

PHILHEALTH MEMBER REGISTRATION FORM

UHC v.1 January 2020

REMINDERS:
PHILHEALTH IDENTIFICATION NUMBER (PIN)
1. Your PhilHealth Identification Number (PIN) is your unique and permanent number.
PURPOSE:
2. Always use your PIN in all transactions with PhilHealth.
3. For Updating/Amendment check the appropriate box and provide details to REGISTRATION UPDATING/AMENDMENT
be accomplished and submit corresponding supporting documents.
Preferred KonSulTa Provider
4. Please read instructions at the back before filling-out this form.

I. PERSONAL DETAILS
NAME NO
LAST NAME FIRST NAME EXTENSION MIDDLE NAME MIDDLE NAME MONONYM
(Jr./Sr./III)
(Checkifapplicableonly)

MEMBER
MOTHER’s
MAIDEN NAME
SPOUSE (If Married)

DATE OF BIRTH PLACE OF BIRTH (City/Municipality/Province/Country) (Please

indicate country if born outside the Philippines) PHILSYS ID NUMBER (Optional)

mm d d y y y y
SEX CIVIL STATUS CITIZENSHIP TAX PAYER IDENTIFICATION NUMBER (TIN) (Optional)
Male Single Annulled FILIPINO FOREIGN NATIONAL
Married Widow/er
Female
Legally Separated DUAL CITIZEN

II. ADDRESS and CONTACT DETAILS

PERMANENT HOME ADDRESS Home Phone Number
Unit/Room No./Floor Building Name Lot/Block/Phase/House Number Street Name

(COUNTRY CODE + AREA CODE + TELEPHONE NUM BER)

Subdivision Barangay Municipality/City Province/State/Country (If abroad) ZIP Code
Mobile Number (Required)

MAILING ADDRESS
Business (Direct Line)
SAME AS ABOVE
Unit/Room No./Floor Building Name Lot/Block/Phase/House Number Street Name
Subdivision Barangay Municipality/City Province/State/Country (If abroad) ZIP Code E-mail Address (Required for OFW)

III. DECLARATION OF DEPENDENTS (Use additional form if necessary)

DATE OF NO Check if
NAME MIDDLE NAME MONONYM
BIR TH with
LAST NAME FIRST NAME EXTENSION
(Jr./Sr./III)
MIDDLE NAME RELATIONSH IP
(mm-dd-yyyy)
CITIZENSHIP
Permanent
Disability
(Checkifapplicableonly)

IV. MEMBER TYPE

DIRECT CONTRIBUTOR INDIRECT CONTRIBUTOR

Employed Private Kasambahay Family Driver
Listahanan LGU-sponsored
Employed Government Migrant Worker
4Ps/MCCT NGA-sponsored
Professional Practitioner Land-Based Sea-Based
Self-Earning Individual Lifetime Member Senior Citizen Private-sponsored
Individual Filipinos with Dual Citizenship / Living Abroad
PAMANA Person with Disability
Sole Proprietor Foreign National
KIA/KIPO PWD ID No. ______________
Group Enrollment Scheme PRA SRRV No. _____________________ ACR
____________________ I-Card No. _____________________ Bangsamoro/Normalization
For PhilHealth Use only:
PROFESSION: (Except Employed, Lifetime Members and Sea- MONTHLY INCOME: PROOF OF INCOME: Point of Service (POS) Financially Incapable
based Migrant Worker)
Financially Incapable

This form may be reproduced and is not for sale Continue at the back
 V. UPDATING/AMENDMENT
Please check: FROM TO
Change/Correction of Name
(Last Name, First Name, Name Extension (Jr./Sr./III) Middle Name)

Correction of Date of Birth

Correction of Sex

Change of Civil Status

Updating of Personal Information/Address/

Telephone Number/Mobile Number/e-mail
Address

FOR PHILHEALTH USE ONLY

Under penalty of law, I hereby attest that the information provided, including the documents I have attached
to this form, are true and accurate to the best of my knowledge. I agree and authorize PhilHealth for the
subsequent validation, verification and for other data sharing purposes only under the following
RECEIVED BY:
circumstances:
Full Name:
 As necessary for the proper execution of processes related to the legitimate and declared
purpose;
______________________________
 The use or disclosure is reasonably necessary, required or authorized by or under the law;
and,
PRO/LHIO/Branch:
 Adequate security measures are employed to protect my information.
_____________________________ Date &

Time:
_________________________________________________ _________________
Please affix right ______________________________
Member’s Signature over Printed Name Date
thumbmark if unable to write

INSTRUCTIONS

1. All information should be written in UPPER CASE/CAPITAL LETTERS. If the information is not applicable, write “N/A.”
2. All fields are mandatory unless indicated as optional. By affixing your signature, you certify the truthfulness and accuracy of all information provided.

3. A properly accomplished PMRF shall be accompanied by a valid proof of identity for first time registrants, and supporting documents to establish
relationship between member and dependent/s for updating or request for amendment.
4. On the PURPOSE, check the appropriate box if for Registration or for Updating/Amendment of information. 5. Indicate
preferred KonSulTa provider near the place of work or residence.
6. For PERSONAL DETAILS, all name entries should follow the format given below. Check the appropriate box if registrant has no middle name and/or
with single name (mononym).

LAST NAME FIRST NAME NAME EXTENSION (Jr./Sr./III) MIDDLE NAME

SANTOS JUAN ANDRES III DELA CRUZ

7. Indicate registrant’s/member’s name as it appears in the birth certificate.

8. The full mother’s maiden name of registrant/member must be indicated as it appears in the birth certificate.
9. Indicate the full name of spouse if registrant/member is married.
10. Indicate the complete permanent and mailing addresses and contact numbers.
11. For updating/amendment, check the appropriate box to be updated/amended and indicate the correct data.
12. For MEMBER TYPE, check the appropriate box which best describes your current membership status.
13. For Direct Contributors, except employed, sea-based migrant workers and lifetime members, indicate the profession, monthly income and proof of
income to be submitted.
14. For Self-earning individuals, Kasambahays and Family Drivers, indicate the actual monthly income in the space provided. 15. In declaring dependents,
provide the full name of the living spouse, children below 21 years old, and parents who are 60 years old and above totally dependent to the
member.
16. Dependents with disability shall be registered as principal members in accordance with Republic Act 11228 on mandatory PhilHealth coverage for
all persons with disability (PWD).
17. The registrant must affix his/her signature over printed name (or right thumbmark if unable to write) and indicate the date when the PMRF was
signed.