Date: ____________________

AUTHORIZATION

To whom it may concern:

I, ______________________________ with PIN _____________________, currently

Name of Member PhilHealth Number
residing at _________________________________________ do hereby authorize the bearer
Address
Mr./Ms. _____________________________ my ________________________ to transact at
Name of Authorized Person Relationship
any PhilHealth Office in my behalf.

Please allow the bearer to process, sign and receive the following transaction/s:
1. _________________________________________________________
2. _________________________________________________________
3. _________________________________________________________
4. _________________________________________________________
5. _________________________________________________________
6. _________________________________________________________

I am hoping for your kind consideration. Thank you very much!

Name and Signature of Member: _______________________________________________________

PIN: _______________________________ Contact No.: ________________________________

Allowable transactions:
1. Correction/change of name
2. Correction of date of birth
3. Change of Civil Status
4. New/Additional or Omission of dependent
5. Generation of MDR only
6. Generation of PhilHealth ID
7. Renewal of Membership (OWP)
8. Others (pls. specify properly)