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Republic of the Philippines

RF-1
PHILIPPINE HEALTH INSURANCE CORPORATION EMPLOYER’S REMITTANCE REPORT
Healthline 441-7444 www.philhealth.gov.ph FOR PHILHEALTH USE
actioncenter@philhealth.gov.ph
Revised February 2014

1 Date Received: __________________ Action Taken:

PHILHEALTH NO.
By: ____________________________
EMPLOYER TIN Signature Over Printed Name
2 COMPLETE EMPLOYER NAME ___________________________________________________________________ 3 EMPLOYER TYPE 4 REPORT TYPE 5 APPLICABLE PERIOD
COMPLETE MAILING ADDRESS __________________________________________________________________ PRIVATE REGULAR RF-1 _________________
__________________________________________________________________ GOVERNMENT ADDITION TO PREVIOUS RF-1
TELEPHONE NO. ______________________________ EMAIL ADRESS _________________________________ HOUSEHOLD DEDUCTION TO PREVIOUS RF-1
6 7 8 Fill out this portion only if 10 NHIP PREMIUM 11
EMPLOYEES INFORMATION declared employee/s has not 9 CONTRIBUTION EMPLOYEE STATUS
PHILHEALTH IDENTIFICATION NUMBER yet been issued his/her PIN
(PIN) NAME EXT. DATE OF BIRTH SEX MONTHLY S-Separated, NE-No Earnings,
LAST NAME FIRST NAME (SR./JR.) MIDDLE NAME (mm-dd-yyyy)
SALARY PS ES NH-Newly Hired /
(M/F) BRACKET Effectivity Date

1.

2.

3.

4.

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6.

7.

8.

9.

10 .

12 13 14 15 PREPARED BY:
ACKNOWLEDGEMENT RECEIPT (PAR/POR/TRANSACTION REFERENCE NO.) SUBTOTAL (PS + ES)
______________________
__________ (To be accomplished on every page)
SIGNATURE OVER PRINTED NAME
ACKNOWLEDGEMENT
APPLICABLE PERIOD REMITTED AMOUNT TRANSACTION DATE NO. OF EMPLOYEES ______________________
Indicate Total Number of RECEIPT OFFICIAL DESIGNATION
employees per page GRAND TOTAL (PS + ES)
(To be accomplished on every page) __________________
DATE

16
UNDER THE PENALTY OF THE LAW, I HEREBY ATTEST THAT THE ABOVE INFORMATION PROVIDED HEREIN ARE TRUE AND CORRECT.

____________________________________________ ________________________________________ _________________________

Signature over printed name Official Designation Date

PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE ACCOMPLISHING THIS FORM