This form may be reproduced and

Republic of the Philippines is NOT FOR SALE

•~iiI~PhiIHealth
..
YOM'PlUflfer br Jlealth
PHILIPPINE HEALTH INSURANCE CORPORATION
Citystate Centre 709 Shaw Boulevard, Paslg City
Call Center (02) 441-7442 • Trunkline (02) 441-7444
www.phllhealth.gov.ph
CSF
(Claim Signature Form)
email: actioncenter@phllhealth.gov.ph
RevisedSeptember 2018

IMPORTANT REMINDERS: Series # LI-L....L_J_..l._.l.I-L1 -L....L_J_..l._..L_.L.....I

WRITEINCAPITALLETTERS AND CHECK THEAPPROPRIATE
PLEASE BOXES.
All information required in this form are necessary.Claim forms with incomplete information shall not be processed.
FALSE/INCORRECTINFORMATION OR MISREPRESENTATION SHALL BE SUBJECTTO CRIMINAL,CML OR ADMINISTRATIVELIABILITIES.
PART 1- MEMBER AND PATIENT INFORMATION AND CERTIFICATION

1. PhilHealth Identification Number (PIN) of Member: m-LI-'--'-...L....L...1...._'__"__J......J1-0

2. Name of Member: 3. Member Date of Birth:

m-m-I
Last Name First Name Name Extension Middle Name month day ._ ......
y..Lea-r..J-...J
(JR/SR/III) (ex:DELA
CRUZJUANJRSIPAG)

4. Phil Health Identification Number (PIN) of Dependent: m-IL.. ...L.....L..._'__"__L......JL.....J__L_JI-O

5. Name of Patient: 6. Relationship to Member:

Last Name First Name Name Extension Middle Name

o child 0 parent Ospouse

(JR/SR/III) (ex:DELA
CRUZ JUANJRSIPAG)

7. Confinement Period: 8. Patient Date of Birth:

a. DateAdmitted: m-m-I b. DateDischarged:m-m-LI....L...J._J'---I m-m-.__I '--I......JL.....J
month day ._ ......
y..Lea-r..J-...J month day year month day year
9. CERTIFICATION OF MEMBER:
Under the penalty of law, , attest that the information' provided in this Form are true and accurate to the best of my knowledge.

Signature OverPrinted Name of Member

DateSigned m-m-I
month
If member/representative is unable to write,
put right thumbmark. Member/Representative
should be assistedby an HCIrepresentative.
Checkthe appropriate box.
day
D
'__L..y-eL..ar...L.....J
Relationshipof the
SignatureOverPrinted Nameof Member'sRepresentative

DateSigned m-m-LI....L...J._J....._j

representativeto the member

month
o
Spouse
0
o
day

Sibling
0
o
Child
year
0
Others,Specify
Parent
_

o Member 0 Representative
Reasonfor signing on
behalf of the member o Memberis incapacitated
Other reasons: _

PART 11- EMPLOYER'S CERTIFICATION 'or '~\:I yerl em' ,- Iy

1.PhilHealthEmployerNumber(PEN): [~I~H
~17 16 131014181 31-[] 2. Contact No.: __ __;;;5wBlI.IO...i,5u;S"'SwSl__
_
3. Business Name: ACCENTURE INC,
BusinessNameof Employer

4. CERTIFICATION OF EMPLOYER:
C"'Titvth"tt."",,,,,,j,,," 3/6 monthly premium contributions plus at least 6 months contributions preceding the 3 months qualifying contributions within 12
of ,::anfi,!"ml>nt,(sulrtici'enl regularity) have been regularly remitted to PhilHealth. Moreover, the information supplied by the member or
our available records"
DateSigned

I hereby consent to the submission and examination of the patient's pertinent medical records for the purpose of verifying the veracity of this claim to effect efficient
processing of benefit payment.
, hereby hold PhilHealth or any of its officers, employees and/or representotives free from any legal liabilities relative to the herein-mentioned consent which' have

D
voluntarily and willingly given in connection with this claim for reimbursement before PhilHealth.
Date Signed m-m-LI....L...J._J_
SignatureOver Printed Name of Member month day year

If member/representative is unable to write,

put right thumbmark. Member/Representative
Relationshipof the
representativeto the patient
o
0
Spouse
Sibling
0
0
Child 0
others, Specify
Parent
_
should be assistedby an HCIrepresentative.
Checkthe appropriate box.
o Patient 0 Representative
Reasonfor signing on
behalf of the patient
o
o Patient is incapacitated
Other reasons:

PART IV - HEALTH CARE PROFESSIONAL INFORMATION

Accreditation No. L......J......L...J-...II-L.I....L....I....JL-J....J......L...JI-O DateSigned m-m-I

SignatureOver Printed Name month day ._ ......
y..Lea'"'r...L.....J

Accreditation No. L......J......L....L...Ii-I 1-0 SignatureOverPrinted Name

DateSigned m-m-L.I
month day
-,-=1:-,-...1
year

Accreditation No. L.....L....J.......L_JI-I 1-0 SignatureOverPrinted Name

Date Signed m-m-L.I
month day
-,-=1year:-'-...1
PART V - PROVIDER INFORMATION AND CERTIFICATION
1. Phil Health Benefits: ICD10orRVSCod.: L FirstCaseRate _ 2. SecondCaseRate _

, certify that services rendered were recorded in the patient's chart and health care institution records and that the herein information given are true and correct.
DateSigned m-m-I
SignatureOverPrinted Name of Authorized HCIRepresentative Official Capacity/Designation month day ......'--ye.L.ar_._
....
 This form may be reproduced and
is NOT FOR SALE
Republic of the Philippines
PHILIPPINE HEALTH INSURANCE CORPORATION
Citystate Centre 709 Shaw Boulevard, Pasig City
Can Center (02) 441-7442 • Trunkline (02) 441-7444
CF-l
(Claim Form 1)
www.philhealth.gov.ph Revised September 2018
email: actioncenter@philhealth.gov.ph
Series # 1

IMPORTANT REMINDERS:
PLEASEWRITE IN CAPITALLETTERS AND CHECK THE APPROPRIATEBOXES.
For local availment, this form together with other PhilHealth claim forms and other supporting documents should be filed within 60 days from date of discharge.
For availment of benefits abroad, this form together with other supporting documents should be filed within 180days from date of discharge.
Representative of the Health Care Institutions (HCI) shall assist the member/authorized representative in filling out this form.
All information required in this form are necessary. Claim forms with incomplete information shall not be processed.
FALSE/INCORRECT INFORMATION OR MISREPRESENTATION SHALL BE SUBJECT TO CRIMINAL, CIVIL OR ADMINISTRATIVE LIABILITIES.

PARTI - MEMBERINFORMATION
1.PhilHealth Identification Number (PIN)of Member: CD- ,-I-,--,--,--,--,--,--,--,--,1-0
2. Nameof Member: 3. Date of Birth:
CD-CD-.__I L-.L......I--'
Last Name First Name Name Extension Middle Name month day year
(JR(SR(III) (ex: DELACRUZ JUAN JR SIPAG)

4. Mailing Address: 5. Sex: 0 Male 0 Female

Unit/Room No./Floor Building Name Lot/Blk/House/Bldg.No Street Subdivision/Village

Barangay City/Municipality Province Country Zip Code

6.Contact Information:

Landline No. (Area Code + Tel. No.) Mobile No. Email Address

7.Patient is the member? 0 Yes, Proceed to Part III 0 No, Proceed to Part II

PART II - PATIENT INFORMATION I I

I, PhilHealth Identification Number (PIN) of Dependent: [IJ-,-I-,--,--,--,--,--,--,--,--,I-O

2. Nameof Patient: 3. Date of Birth:
CD-CD -I,--,--,L-.L.....l
Last Name First Name Name Extension Middle Name month day year
(JR(SR(III) (ex: DELA CRUZ JUAN JR SIPAG)

4. Realtionship to Member: 0 Child 0 Parent 0 Spouse 5. Sex: 0 Male 0 Female

PARTIII - MEMBERCERTIFICATION

Under the penalty of law, I attest that the information I provided in this Form are true and accurate to the best of my knowledge.

Signature Over Printed Name of Member Signature Over Printed Name of Member's Representative

Date Signed CD -CD -,-I -'----L--'--' DateSigned [IJ-CD-LI -L--'---'--'

month day year month day year

0 0 0

D
If member/representative is unable to write, Relationship of the Spouse Child Parent
put right thumbmark. Member/Representative representative to the member 0 Sibling 0 Others, Specify _
should be assisted by an HCI representative.
Check the appropriate box. o
o
o Member 0 Representative
Reason for signing on
behalf of the member
Member is incapacitated
Other reasons: ------------

PARTIV - EMPLOYER'SCERTIFICATION I u! •

1.PhilHealth Employer Number (PEN): ffi-1 2.Contact No.: 58_0_5_8_8_8 _

3. BusinessName:
ACCENTURE INC.
Business Name of Employer

4. CERTIFICATION
OFEMPLOYER:
"This is to certify that the . ed 3/6 menthly premium contributions plus at least 6 months contributions preceding the 3 months qualifying contributions within 12
irst da of confinement (sufficient regularity) have been regularly remitted to PhilHealth. Moreover, the information supplied by the member or
Port on iste ith our available records,"

HR SENIOR ANALYST Date Signed CD -CD -I.__..___,_-,--_,

Official Capacity/Designation month day year

PARTV - FOR PHILHEALTH USEONLY

Date Received: By:

I LHIO
PRO LHIO/PRO Signature Over Printed. Name