Professional Documents
Culture Documents
PHILHEALTH
CLAIM FORM 1
Revised May 2000
Note: This form together with Claim Form 2 should be filed with PhilHealth within 60 calendar days from date of discharge.
PART I - MEMBER'S CERTIFICATION (Member to Fill in All Items/Indigent to be Assisted by Hospital Representative)
1. Type of Membership Employed: Private Sector Gov't. Sector Individually paying: Self-employed OFW Others OWWA
Indigent Retiree/Pensioner: SSS GSIS Military Judiciary
Identification No.
6. Address of Member
No., Street Barangay
7. Name of Spouse
Last Name First Name
Middle Name
Not Applicable
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 the data 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
cut here
Member's Copy This portion should be completely filled up, detached by the hospital and given to member
ACKNOWLEDGEMENT RECEIPT
Name of Member : SSS/GSIS/MEC/PhilHealth No. :
Name of Patient : Confinement Period :
Name of Hospital : PhilHealth Forms Received by :
Address of Hospital : Date :
IMPORTANT
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-1 and ME-5 and/or applicable receipts
2. Beneficiary/Hospital representative to attach the following supporting document/s for:
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 )
e) SSS partial disability pensioners - certificate from SSS indicating coverage/period of pension
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
This form may be reproduced and is NOT FOR SALE
Middle Name
Identification No.
6. Address of Member
No., Street Barangay
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
FOR PHILHEALTH USE
1.
2.
3.
4.
5.
6.
7.
8.
9.
10
11.
12.
13.
14.
15.
TOTAL
NOTE: Official Receipts for drugs and medicines purchased by patient must be attached to this claim.
PART IV - X-RAY, LABORATORIES AND OTHERS
Unit Actual Benefit Claim
Particulars Qty. Price Charges Hospital Patient
A. X-ray/Lab.
1.
2.
3.
4.
5.
B. Supplies
1.
2.
3.
4.
5.
C. Others
1.
2.
3.
4.
5.
TOTAL
NOTE: Official Receipts for laboratory procedures performed outside the hospital during this confinement period must be attached to this claim.
PART V - CERTIFICATION of PATIENT/MEMBER
I hereby certify that:
The amount of P was deducted from the hospital charges.
The amount of P was deducted from the professional fee charges.
The amount of P was paid for medicines/lab. acquired outside the hospital during this confinement
( Official Receipts attached ).
No deduction was made from the hospital charges.
No deduction was made from the professional fee charges.
PHILHEALTH
CLAIM FORM 3 PATIENT'S CLINICAL RECORD
Revised May 2000
Note: This form should be filed with PhilHealth within 60 calendar days from date of discharge.
Case No.:
Admission:
m m d d y y y y AM/PM
Date: Time: :
Middle Name
Printed Name & Signature of Admitting Officer
5. Admitting Diagnosis:
6. Chief Complaint:
Chest/Lungs:
CVS:
Abdomen:
GU ( IE ):
Skin/Extremities:
Neuro Examination:
10. Course in the Wards:
11. Pertinent Laboratory and Pertinent Diagnostic Findings: ( CBC, Urinalysis, Fecalysis, X-ray, Biopsy, etc. )
13. Discharge:
m m d d y y y y AM/PM
a. Date: b. Time: :
c. Final Diagnosis:
d. Condition on Discharge:
Right thumbmark
(In case patient and representative could not write) Printed Name & Signature of Witness to Thumbmark
This form may be reproduced and is NOT FOR SALE
NOTE: THIS FORM TOGETHER WITH CLAIM FORM 1 SHOULD BE FILED WITH PHILHEALTH WITHIN 60 CALENDAR DAYS FROM DATE OF DISCHARGE.
3. Name of Facility
4. Address of Facility
No., Street Barangay
First Name
Middle Name
TOTAL
Medicines & Supplies bought & laboratory
performed outside facility during confinement period
12. CERTIFICATION of FACILITY: 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 (Provider/s to Fill in Respective Portions )
13. Complete Final Diagnosis 14. ICD-10 Code: FOR PHILHEALTH USE
RVS Code
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.
PHILHEALTH MATERNITY CARE
CLAIM FORM 4A PACKAGE
April 2003
NOTE: THIS FORM TOGETHER WITH CLAIM FORM 4 SHOULD BE FILED WITH PHILHEALTH WITHIN 60 CALENDAR DAYS FROM DATE OF DISCHARGE.
Name of Physician/Midwife:
Name of Facility:
Address of Facility:
Name of Patient:
PART I - PRENATAL
Visit No. 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th
Date of visit
A. Determine AOG in weeks
B. Obtain vital signs
a. Wt
b. HR
c. RR
d. BP
e. T
2. Obtain Vital Signs HR: _____ RR: _____ BP: _____ T: ____
5. Perform IE
BOW:__________________ Cervical Effacement: _______________ Presentation: ____________
Cervical dilatation: ___________________ Station: ________________
Q. Monitor during Immediate Postpartum Period BP: ____ HR: ____RR: ____T: ____
NOTE: THIS FORM TOGETHER WITH CLAIM FORM 4 SHOULD BE FILED WITH PHILHEALTH WITHIN 90 CALENDAR DAYS FROM DATE OF DISCHARGE.
Name of Physician/Midwife:
Name of Facility:
Address of Facility:
Name of Patient:
DONE REMARKS
1. Newborn Care
3. Newborn Immunization
4. Family Planning
NOTE: THIS FORM TOGETHER WITH CLAIM FORM 1 SHOULD BE FILED WITH PHILHEALTH WITHIN 60 CALENDAR DAYS FROM DATE OF COMPLETION OF TREATMENT
4. Name of Member
Last Name PIN
First Name
Middle Name
5. Address of Member
No., Street Barangay
M
Middle Name maintenance
F
13.CERTIFICATION of HOSPITAL/DOTS CENTER: I certify that the services rendered are duly recorded in the patient's chart and that the information
in this form are true and correct.
Signature Over Printed Name of Authorized Representative Date Signed Official Capacity