Welcome to Scribd, the world's digital library. Read, publish, and share books and documents. See more
Download
Standard view
Full view
of .
Save to My Library
Look up keyword
Like this
34Activity
0 of .
Results for:
No results containing your search query
P. 1
Claim Forms

Claim Forms

Ratings:

4.5

(2)
|Views: 6,192 |Likes:
Published by api-3836762

More info:

Published by: api-3836762 on Oct 18, 2008
Copyright:Attribution Non-commercial

Availability:

Read on Scribd mobile: iPhone, iPad and Android.
download as PDF, TXT or read online from Scribd
See more
See less

03/18/2014

pdf

text

original

PHILHEALTH
CLAIM FORM 1
Note: This form together with Claim Form 2 should be filed with PhilHealth within 60 calendar days from date of discharge.

Last Name
First Name
Middle Name

No., Street
Barangay
Municipality/City
Province
Zip Code
Last Name
First Name
Middle Name

Last Name
First Name
Middle Name

Legitimate spouse who is not an NHIP Member.
Parent who is 60 years old and above, not an NHIP member/retiree/pensioner and
Unmarried and unemployed, legitimate, legitimated,
wholly dependent on me for support.
acknowledged and illegitimate or legally adopted/step
Unmarried child 21 years old & above with physical/ mental disability, congenital or
child, below 21 years old.
acquired and wholly dependent on me for support.
13. CERTIFICATION of MEMBER: I certify that the foregoing information are true and correct and that the three(3) applicable monthly contributions had been
paid within six(6) month prior to the month of this confinement.
Signature of Member
Printed Name & Signature of Witness to Thumbmark
If unable to write, affixRight thumbmark
15. Address of Employer ( No., Street, Barangay/Municipality/City, Province, Zip Code )
No., Street
Barangay
Municipality/City
Province
Zip Code
16. CERTIFICATION of EMPLOYER: This is to certify that three(3) applicable monthly contributions were collected during the six(6) month period prior to the
month of this confinement and that thedata supplied by the member on Part I are true and conform with our available records.
Signature Over Printed Name of Authorized Representative
Date Signed
Official Capacity
Member's Copy
This portion should be completely filled up, detached by the hospital and given to member
Name of Member :
SSS/GSIS/MEC/PhilHealth No. :
Name of Patient :
Confinement Period :
Name of Hospital :
PhilHealth Forms Received by :
Address of Hospital :
Date :
This form may be reproduced and is NOT FOR SALE
ACKNOWLEDGEMENT RECEIPT
PART II - EMPLOYER'S CERTIFICATION (For employed members only)
Revised May 2000
PART I - MEMBER'S CERTIFICATION (Member to Fill in All Items/Indigent to be Assisted by Hospital Representative)
Retiree/Pensioner:
SSS
Employed:
Individually paying:
GSIS
Military
Judiciary
Single
Married
Separated
Widow/er
Male
Female
Identification No. of Employer
Not Applicable
Patient is the Member
cut here
1. Type of Membership
Identification No.
Private Sector
Gov't. Sector
OFW
3. Date of Birth
mmd dy y y y
2. Name of Member
4. Civil Status
6. Address of Member
5. Sex
9. Date of Birth
mmd dy y y y
7. Name of Spouse
8. Name of Patient
11. Sex
10. Age
Male
Female
12. Relationship of Patient to Member ( Check applicable box if patient is a dependent )
14. Registered Name of Employer
OWWA
Self-employed
Indigent
Others

1. For currently employed member, the original and properly accomplished Form 1 is sufficient. In case item no. 16 ( Certification of Employer ) is not properly accomplished ( ex. separated from employment, but contribution is still qualified for the confinement period ) submit RF-1and ME-5 and/or applicable receipts

2. Beneficiary/Hospital representative to attach the following supporting document/s for:
a) Individually paying ( voluntary, self-employed or OFW members),any of the following:

Official Receipts of PhilHealth accredited collecting banks or PhilHealth Bank Receipts (PBR)
Duly validated MI-5 ( Contributions Payment Return Form ) for individually paying members starting January 2000
Official Receipts issued by PhilHealth ( for over the counter payments )

b) SSS/GSIS Retirees,any of the following:

Latest pension voucher
Copy of bank account passbook ( with pages indicating name of pensioner and latest pension entry )
Retirement Certificate issued by the GSIS/SSS

c) AFP/PNP Retirees,any of the following:

General or Special Orders
Latest pension voucher
Certification of 120 monthly Medicare/NHIP contributions from the GSIS or from previous employer
Service record

d) Retired Judges,any of the following:

Certificate of retirement from the Office of the Court Administration (OCA)
Certification of 120 monthly Medicare/NHIP contributions from the GSIS or from previous employer
Service record

e) SSS partial disability pensioners - certificate from SSS indicating coverage/period of pension
f) Dependents of a, b, c, d and e - approved M1bor E1/E4 for SSS membersor
SPOUSE - copy of marriage contract
CHILD- copy of birth or baptismal certificate

Illegitimate/Legitimated child - birth certificate acknowledged by the father/mother or notarized affidavit of support
Legally adopted child - legal adoption paper or notarized affidavit that child is legally adopted
Step-child

.birth or baptismal certificate with copy of marriage contractor
.affidavit by the step-mother or step-father
PARENT- affidavit of support ( original or Certified True Copy )
g) OWWA member/dependent - Certified True Copy of Medicare Eligibility Certificate ( MEC )
Legend:

RF-1 - Quarterly Remittance Report form
ME-5 - Contributions Payment Return form for employed sector
MI-5

- Contributions Payment Return form for individually paying members
M1b
- Membership Data Record form for individually paying
E1
- SSS Membership form for new member
E4
- SSS Member's Data Ammendment form
IMPORTANT
PHILHEALTH
CLAIM FORM 2
Note: This form together with Claim Form 1 should be filed with PhilHealth within 60 calendar days from date of discharge.
Primary
Secondary
Tertiary
Ambulatory
No., Street
Barangay
Municipality/City
Province
Zip Code
Last Name
First Name
Middle Name
6. Address of Member
No., Street
Barangay
Municipality/City
Province
Zip Code
7. Name of Patient
8. Age 10. Admission Diagnosis
Last Name
First Name
9. Sex
Middle Name
11.
a. Date Admitted
c. Date Discharged
e. Claimed No.of Days
b. Time Admitted
:
d. Time Discharged
:
12. Hospital/Ambulatory Services

a. Room and Board
b. Drugs and Medicines ( Part III for details )
c. X-ray/Lab. Test/Others ( Part IV for details )
d. Operating Room Fee
e. Medicines bought & laboratory performed

outside hospital during confinement period
TOTAL
13. CERTIFICATION of HOSPITAL/AMBULATORY CLINIC: I certify that the services rendered are duly recorded in the patient's chart and that the information
given in this form are true and correct.
Signature Over Printed Name of Authorized Representative
Date Signed
Official Capacity
PART II - PROFESSIONAL DATA AND CHARGES ( Doctor/s to Fill in Respective Portions )
14. Complete Final Diagnosis
Relative Unit Value
Ordinary
Intensive
Catastrophic
16. Name of Attending Physician
Illness Code
17.PHIC Accreditation No.
18. BIR/TIN No.
-
-
Reduction Code
19. Services Performed
20. Actual
P
P
P
21. Name of Surgeon
Reduction Code
22.PHIC Accreditation No.
23. BIR/TIN No.
-
-
24. Services Performed
25. Actual
P
P
P
Date of Operation
26. Name of Anesthesiologist
Reduction Code
27.PHIC Accreditation No.
28. BIR/TIN No.
-
-
29. Services Performed
30. Actual
P
P
P
NOTE:Anyone who supplies false or incorrect information requested by this or a related form or commits misrepresentation shall be subject to criminal,civil or administrative prosecution
under the law.All data required on this form are necessary for adjudication of the claim.PhilHealth will not adjudicate any claim where forms are not properly or completely accomplished.
Patient
Patient
Professional Charges
SurgeonBenefit Claim
Professional Charges
Physician
PROVIDER'S CERTIFICATION
HEALTH CARE
REDUCTION CODE
This form may be reproduced and is NOT FOR SALE
BENEFIT CLAIM
ACTUAL HOSPITAL/
PART I - HOSPITAL DATA AND CHARGES ( Hospital to Fill in All Items )
PATIENT
Revised May 2000
Patient
FOR PHILHEALTH USE
PhysicianBenefit Claim
Professional Charges
Benefit Claim
f. Date of Death
HOSPITAL
AMBULATORY CHARGES
MF
4. Address of Hospital/Ambulatory Clinic
1. PhilHealth Accreditation No.
2. Accreditation Category
Confinement Period
mm d dy y y y
AM/PM
AM/PM
(If Applicable)
m md dy y y y
15. Case Type
Signature & Date Signed
Signature & Date Signed
Signature & Date Signed
mm d dy y y y
AM/PM
3. Name of Hospital/Ambulatory Clinic
5. Name of
5. Name of Member and Identification
Identification No.
Signature & Date Signed

Activity (34)

You've already reviewed this. Edit your review.
1 hundred reads
1 thousand reads
Elbert Palor liked this
Lorna Nefiel liked this
Jen Sardeng liked this
quimosave liked this
Elwyn P. Biason liked this

You're Reading a Free Preview

Download
/*********** DO NOT ALTER ANYTHING BELOW THIS LINE ! ************/ var s_code=s.t();if(s_code)document.write(s_code)//-->