0PMRF

PHILHEALTH MEMBER REGISTRATION FORM

UHC v.1 January 2020

19 -0 0 0 5 1 1 5 3 5 - 7
REMINDERS:
PHILHEALTH IDENTIFICATION NUMBER (PIN)
1. YourPhilHealthIdentificationNumber(PIN)isyouruniqueandpermanent
number. PURPOSE:
2. Always useyourPINinalltransactions withPhilHealth. REGISTRATION  UPDATING/AMENDMENT
3. For Updating/Amendmentchecktheappropriateboxandprovidedetails to Preferred KonSulTaProvider
beaccomplishedandsubmitcorrespondingsupportingdocuments.
4. Pleasereadinstructionsatthebackbeforefilling-outthisform.
I. PERSONAL DETAILS
NAME NO
LAST NAME FIRST NAME EXTENSION MIDDLE NAME MIDDLE
NAME
MONONYM
(Jr./Sr./III) (Check i fapp li cable only)

MEMBER OLIVEROS ROSEMARIE BAUTISTA

MOTHER’s
MAIDEN NAME PERDIDO EPIFANIA OBISPO
SPOUSE
(If Married) OLIVEROS ARNEL DIMAYA
DATE OF BIRTH PLACE OF BIRTH (City/Municipality/Province/Country)
(Please indicate country if born outside the Philippines) PHILSYS ID NUMBER (Optional)
0 4 0 4 1 9 6 2
mm d d y y yy COLO DINALUPIHAN BATAAN
SEX CIVIL STATUS CITIZENSHIP TAX PAYER IDENTIFICATION NUMBER (TIN) (Optional)
Male Single Annulled  FILIPINO FOREIGNNATIONAL 1 4 3 8 7 1 2 5 2
 Female  Married
DUAL CITIZEN
Widow/erLegallySepar
ated
II. ADDRESS and CONTACT DETAILS
PERMANENT HOME ADDRESS Home Phone Number
Unit/Room No./Floor BuildingName Lot/Block/Phase/House Number StreetName
311 A. MABINI ST.
(COUN TRY C OD E + AR EA CODE + TELEPHONE NUM BER)
Subdivision Barangay Municipality/City Province/State/Country(Ifabroad) ZIPCode
Mobile Number (Required)
CENTRO 1 SANCHEZ MIRA CAGAYAN 3518
MAILINGADDRESS SAME ASABOVE
09166074116
Unit/Room No./Floor Building Name
 Lot/Block/Phase/HouseNumber StreetName Business (Direct Line)
311 A. MABINI ST.
Subdivision Barangay Municipality/City Province/State/Country(Ifabroad) ZIPCode
E-mail Address (Required for OFW)
CENTRO 1 SANCHEZ MIRA CAGAYAN 3518
III. DECLARATION OFDEPENDENTS (Use additional form ifnecessary)

DATE OF NO Check if
NAME MIDDLE MONONYM
BIRTH
LAST NAME FIRST NAME EXTENSION
(Jr./Sr./III)
MIDDLE NAME RELATIONSHIP
(mm-dd-yyyy)
CITIZENSHIP NAME
with
Permanent
(Checkifapplicableonly)
Disability

OLIVEROS ARNEL DIMAYA HUSBAND 09/17/57 FILIPINO

OLIVEROS AR-JAY BILGATES BAUTISTA SON 12/30/98 FILIPINO
OLIVEROS ARMIL MANUEL BAUTISTA SON 01/10/2000 FILIPINO
MOTHE
PERDIDO EPIFANIA OBISPO R
01/06/40 FILIPINO
IV. MEMBER TYPE
DIRECT CONTRIBUTOR INDIRECTCONTRIBUTOR
EmployedPrivate Kasambahay FamilyDriver
Listahanan LGU-sponsored
Employed Government MigrantWorker
4Ps/MCCT NGA-sponsored
ProfessionalPractitioner Land-Based Sea-Based
SeniorCitizen Private-sponsored
Self-EarningIndividual LifetimeMember
PAMANA Person withDisability
Individual Filipinos with Dual Citizenship / LivingAbroad
KIA/KIPO PWD IDNo.
SoleProprietor ForeignNational
Group EnrollmentScheme PRA SRRVNo _____________________ Bangsamoro/Normalization
________ ACR I-CardNo ____________________ For PhilHealth Use only:
PointofService(POS)FinanciallyIncapable

FinanciallyIncapable
PROFESSION: (Except Employed, Lifetime Members and MONTHLY INCOME: PROOF OF INCOME:
Sea-based Migrant Worker)

TEACHING ₽28,028.00 PAYSLIP



Thisformmaybereproducedandisnotforsale Continue at theback

 V. UPDATING/AMENDMENT
Please check: FROM TO
Change/Correction of Name
(Last Name, First N ame, Name Extension (Jr./Sr./III) Middle Name)

Correction of Date ofBirth

Correction ofSex

Change of CivilStatus
Updating of PersonalInformation/Address/
 Telephone Number/MobileNumber/e-mail
Address
FOR PHILHEALTH USE ONLY
Under penalty of law, I hereby attest that the information provided, including the documents I
have attached to this form, are true and accurate to the best of my knowledge. I agree and
RECEIVED BY:
authorize PhilHealth for the subsequent validation, verification and for other data sharing
purposes only under the following circumstances:

 As necessary for the proper execution of processes related to the legitimateand Full Name:
declared purpose;
 The use or disclosure is reasonably necessary, required or authorized by or under the ____________ PRO/LHIO/Branch:
law;and,
 Adequate security measures are employed to protect myinformation.
___________

Date & Time:

ROSEMARIE B. OLIVEROS 07-24-2020
Pleaseaffixright
Member’sSignatureoverPrintedName Date ____________
thumbmark if unable to write

INSTRUCTIONS

1. All information should be written in UPPER CASE/CAPITAL LETTERS. If the information is not applicable, write“N/A.”
2. All fields are mandatory unless indicated as optional. By affixing your signature, you certify the truthfulnessand accuracy of all
information provided.
3. A properly accomplished PMRF shall be accompanied by a valid proof of identity for first time registrants, andsupporting
documents to establish relationship between member and dependent/s for updating or request for amendment.
4. On the PURPOSE, check the appropriate box if for Registrationor for Updating/Amendmentofinformation.
5. Indicate preferred KonSulTa provider near the place of work orresidence.
6. For PERSONAL DETAILS, all name entries should follow the format given below. Check the appropriate box if registrant hasno
middle name and/or with single name (mononym).

LASTNAME FIRSTNAME NAMEEXTENSION(Jr./Sr./III) MIDDLENAME

OLIVEROS ROSEMARIE BAUTISTA

7. Indicateregistrant’s/member’snameasitappearsinthebirthcertificate.
8. The full mother’s maiden name of registrant/member must be indicated as it appears in the birthcertificate.
9. Indicate the full name of spouse if registrant/member ismarried.
10. Indicate the complete permanent and mailing addresses and contactnumbers.
11. For updating/amendment, check the appropriate box to be updated/amended and indicate the correctdata.
12. For MEMBER TYPE, check the appropriate box which best describes your current membershipstatus.
13. For Direct Contributors, except employed, sea-based migrant workers and lifetime members, indicate the profession, monthly
income and proof of income to besubmitted.
14. For Self-earning individuals, Kasambahaysand Family Drivers, indicate the actual monthly income in the spaceprovided.
15. In declaring dependents, provide the full name of the living spouse, children below 21 years old, and parents who are 60 yearsold
and above totally dependent to the member.
16. Dependents with disability shall be registered as principal members in accordance with Republic Act 11228 on mandatory
PhilHealth coverage for all persons with disability(PWD).
17. The registrant must affix his/her signature over printed name (or right thumbmark if unable to write) and indicatethe date when the
PMRF was signed.