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  • Application Form For Accreditation of Professionals: Philippine Health Insurance Corporation Accreditation Department

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    This document is an application form for accreditation of professionals with the Philippine Health Insurance Corporation (PHIC). It requests information such as the applicant's name, contact details, profession, licensure and membership status, education history, place of practice, and hospital affiliations. Upon completion, the form will be processed by PHIC to determine the applicant's accreditation status and issue a PHIC identification number.

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    This document is an application form for accreditation of professionals with the Philippine Health Insurance Corporation (PHIC). It requests information such as the applicant's name, contact details, profession, licensure and membership status, education history, place of practice, and hospital affiliations. Upon completion, the form will be processed by PHIC to determine the applicant's accreditation status and issue a PHIC identification number.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    9 views2 pages

    Application Form For Accreditation of Professionals: Philippine Health Insurance Corporation Accreditation Department

    Uploaded by

    uvch
    This document is an application form for accreditation of professionals with the Philippine Health Insurance Corporation (PHIC). It requests information such as the applicant's name, contact details, profession, licensure and membership status, education history, place of practice, and hospital affiliations. Upon completion, the form will be processed by PHIC to determine the applicant's accreditation status and issue a PHIC identification number.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 2

    Republic of the Philippines

    PHILIPPINE HEALTH INSURANCE CORPORATION


    ACCREDITATION DEPARTMENT
    City State Centre, 709 Shaw Blvd. Oranbo, Pasig City
    Tel No. 637-6265 Trunk line 637-9999 loc 1216, 1217,1223
    Telefax. 637-2527

    1x1
    Photo

    PHIC FORM No. P-AC-1

    DATE RECEIVED:_____________________

    APPLICATION FORM FOR ACCREDITATION OF PROFESSIONALS


    Please be reminded that incompletely filled up application form will be returned without any action.
    Accreditation No.

    PhilHealth Identification No.

    1. PROFESSIONAL'S CLASSIFICATION

    2. STATUS OF APPLICATION

    GENERAL PRACTITIONER
    DENTIST
    MEDICAL SPECIALIST:___________________
    Subspecialty : _______________________

    INITIAL
    UPGRADING

    RENEWAL
    REACCREDITATION

    3. NAME OF APPLICANT
    Last

    Middle

    First

    4. SEX
    Male

    5. CIVIL STATUS
    Single

    Female

    Married

    7. BIRTHDATE (mm/dd/yyyy)

    6. For Females Only


    Widow

    Mother's Last Name when Single

    Separated
    8. TIN NUMBER

    9. E-MAIL ADDRESS

    10. FAX No.

    11. RESIDENTIAL ADDRESS


    No. / St. / Brgy.

    Municipality / City

    Province

    Zip Code

    Telephone No.

    12. MAILING / BILLING ADDRESS


    No. / St. / Brgy.

    Municipality / City

    Province

    Zip Code

    Telephone No.

    13.PRESENT PLACE OF PRACTICE


    No. / St. / Brgy.

    Municipality / City

    Province

    Zip Code

    14. COLLEGE / UNIVERSITY

    Telephone No.

    DEGREE

    YEAR GRADUATED

    15. PRC No.

    Date Issued (mm/dd/yy)

    Valid up to (mm/dd/yy)

    16. PMA / PDA No.

    Date Issued (mm/dd/yy)

    Valid up to (mm/dd/yy)

    17. COMPONENT SOCIETY

    REGULAR MEMBER

    18. SPECIALTY SOCIETY

    LIFE MEMBER

    REGULAR MEMBER
    LIFE MEMBER

    19. HOSPITAL AFFILIATION


    HOSPITAL NAME

    ADDRESS

    STATUS OF EMPLOYMENT
    FT / PT / ON CALL / VISITING
    (Please see footnote below)

    THIS PORTION IS TO BE FILLED OUT BY PHILHEALTH


    ID Released

    Date:

    By:

    ID Mailed

    Date:

    By:

    Full Time (FT) : renders hospital service at least 40 hrs/wk.


    On Call: MS attending to housecases or GP not regularly holding 24 hr. duty .
    NDT/MIRF/ecv19/comp2:docviyo/rmlh/amo/rev_prof_form/062101

    Part Time (PT): renders hospital service at least 10hrs/wk.


    Visiting: MS regularly holding private clinic and/or attending to private
    patients in the hospital, regardless of time duration.

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