________________ Date

Membership/Collection Section PHILIPPINE HEALTH INSURANCE CORPORATION

Sir/Madam: I,_________________________________________, born on _____________________ with an assigned

Name of Member (Last name, First name, Middle name) Birth date (month date, year)

PhilHealth Identification Number (PIN) of

and a

paying member of the National Health Insurance Program would like to request for the issuance of: PhilHealth Identification Card (PIC) Member Data Record (MDR) Contribution history Certificate of Premium Payment (CPP) Certification for lost payment receipt for the purpose of: Replacement of Lost PhilHealth ID or PNC (with attached Affidavit of Loss) Replacement of Damaged PhilHealth ID or PNC (attached damaged card) Availing PhilHealth benefits as required by the hospital Others:

Hoping for your prompt response on this request. Thank you.

_____________________________ (Signature over Printed Name)

Address: Contact No:

_______________________________________________________________
Lot/Block no./ Street name Barangay Municipality/City Province

___________________________

Email address: _____________________________________________