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PhilHealth_ClaimForm3

PhilHealth_ClaimForm3

Ratings: (0)|Views: 22,497|Likes:
Published by thegomom
To be filled and signed by doctor.
To be filled and signed by doctor.

More info:

Categories:Types, Legal forms
Published by: thegomom on Feb 18, 2011
Copyright:Attribution Non-commercial

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07/10/2013

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This form may be reproduced and is NOT FOR SALEIMPORTANT REMINDERS:
THIS FORM SHOULD BE FILED TOGETHER WITH PHILHEALTH CLAIM FORMS 1 AND 2 WITHIN
60 CALENDAR DAYS
FROM DATE OF DISCHARGE.FOR LEVEL 1 FACILITY, THIS FORM SHALL BE REQUIRED FOR ALL BENEFIT CLAIMS.FOR LEVELS 2, 3 AND 4 FACILITIES, THIS FORM IS REQUIRED IN CASES OF: 1) EMERGENCY/TRANSFERRED 2) LESS THAN 24 HOURS ADMISSION 3) CASE TYPE 'D' DIAGNOSIS.THIS FORM SHALL BE REQUIRED FOR ALL CLAIMS ON MATERNITY CARE PACKAGE.
 AMPM
 
Year Day 
:
Vital Signs
Month
BP :HEENT9. Pertinent Laboratory and Diagnostic Findings: ( CBC, Urinalysis, Fecalysis, X-ray, Biopsy, etc. )
:
6. Brief History of Present Illness / OB History:CR:AbdomenTemperature:RR:
::
8. Course in the Wards (attach additional sheets if necessary):Neuro Examination
:
Skin/Extremities
:
CVS
::
GU ( IE )
hh-mmhh-mmhh-mm
7. Physical Examination ( Pertinent Findings per System )General Survey:Chest/Lungs10. Disposition on Discharge:
CF3
(Claim Form)
revised February 2010
2. Name of Patient
PART I - PATIENT'S CLINICAL RECORD
1. PhilHealth Accreditation No. (PAN) - Institutional Health Care Provider:
Month Day Yea
Last Name, First Name, Middle Name (example: Dela Cruz, Juan Jr., Sipag)
Time Admitted:3. Chief Complaint / Reason for Admission:4. Date Admitted:ImprovedExpired AbscondedHAMATransferred Time Discharged:
hh-mm
5. Date Discharged:

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