Republic of the Philippines

PHILIPPINE HEALTH INSURANCE CORPORATION

Citystate Centre, 709 Shaw Boulevard, Pasig City
Call Center (02) 441-7442 Trunkline (02) 441-7444
www.philhealth.gov.ph

Case No. _______________

Annex “C2 – RF/RHD”

CHECKLIST OF MANDATORY AND OTHER SERVICES

Rheumatic Fever/Rheumatic Heart Disease

Tranche 2
HEALTH CARE INSTITUTION (HCI)

ADDRESS OF HCI

A. PATIENT 1. Last Name, First Name, Middle Name, Suffix SEX

¨ Male ¨ Female
2. PhilHealth ID Number cc - ccccccccc -c
B. MEMBER 1. Last Name, First Name, Middle Name, Suffix
(answer only if
the patient is a
dependent) 2. PhilHealth ID Number cc - ccccccccc - c

OTHER SERVICES, as
MANDATORY SERVICES Status Status
needed
Tick one, whichever is Dates of
applicable injection:
1. _____
¨ penicillin G benzathine 2. _____
(benzathine 3. _____
benzylpenicillin), 1.2M 4. _____
A. For rheumatic fever

units, vial (MR) (IM) every 5. _____

28 days 6. _____
7. _____
OR
¨ Oral secondary Start date
prophylaxis, tick one of oral
¨ phenoxymethyl prophylaxis:
penicillin _________
(penicillin V)
¨ erythromycin Date of last
intake:
_________

As of January 2019 Page 1 of 2 of Annex C – RF/RHD

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 OTHER SERVICES, as
MANDATORY SERVICES Status Status
needed
Tick one, whichever is Dates of
applicable injection:
1. _____
¨ penicillin G benzathine 2. _____
(benzathine 3. _____
benzylpenicillin) , 1.2M 4. _____
units, vial (MR) (IM) every 5. _____
B. For RF/RHD

21 days 6. _____
7. _____
8. _____
OR 9. _____
10. _____
¨ Oral secondary Start date
prophylaxis, tick one of oral
¨ phenoxymethyl prophylaxis:
penicillin _________
(penicillin V) Date of last
¨ erythromycin intake:
_________
2D Echocardiography Date/s:
D. Others C. Lab exam

aspirin
prednisone
antacid
E. Date/s of updates* in the Date/s
RF/RHD Registry
* The RF/RHD Coordinator should update the information of the patient in the registry at least every six months.

Conforme by Documents reviewed by

(Printed name and signature) (Printed name and signature)

Parent/Guardian/Patient RF/RHD Coordinator
Date signed (mm/dd/yyyy) Date signed (mm/dd/yyyy)

Certified correct by: Certified correct by:

(Printed name and signature) (Printed name and signature)

Attending Physician Executive Director/Chief of Hospital/
Medical Director/ Medical Center Chief
PhilHealth PhilHealth
Accreditation No. Accreditation No.

Date signed (mm/dd/yyyy) Date signed (mm/dd/yyyy)

As of January 2019 Page 2 of 2 of Annex C – RF/RHD

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