PhilHealth Your Parmer in Health wn PHILHEALTH DENTIFICATION NUMBER (PIN) 1. Your Phitieath Identfication Nunber (PIN) is your unique and permanent : ‘ouete PURPOSE: 2. Always use your PIN in all transactions with PhiHealtn REGISTRATION [] UPDATING/AMENDMENT 3. For Updating/Amendment check the appropiate box and provide deta be accomplished and submt corresponding supporting documents. Bh 4. Please read instuctions atthe back before flingout this form. PMRF PHILHEALTH MEMBER REGISTRATION FORM| UHC v.t January 2020 LAST NAME FIRST NAME ojo Jeaise Oo )ATE OF BIRTH. \CE OF BIRTH cymuncpanyrownentourry) | ss indintscourtyH bom atid he Pipes PHILSYS 1D NUMBER (Optional) I l IZENSHIP- O Fupmo Douaccrrzen C1 FOREIGN NATIONAL ing Name LoUBlock/Phase/House Number Steet Name PAYER IDENTIFICATION NUMBER (T9) (Optional) [Subdivision Barangay WanicipaligiCty Provines/StatiCountry fabroad) 2 Code ile Number (Required) Jfwiiinc ADDRESS Clsame as aBove peer |UnivRoom NouFleor Bulding Name LoUBlock/Phase/Mouse Number Street Name (Business (Directing) (COimTRY CCOET ARIA CODES TELEPHONE ORE) [Subavision ‘anicipaliyiGiy Provines/StatiGountry (Wabroad) Barangay MIDDLE NAME iP Code z DIRECT CONTRIBUTOR INDIRECT CONTRIBUTOR ‘Employed Private Okasambaray =O) Family Driver Llemployed Government EF] Migrant Workar Flushes 0 Labsogmeret Llprotesiona Practtorer Cltnd-Based Clseaased ISTE El ears Oset-Eaming individual DLitetime Member Osenior Citizen o Private-sponsored individual Filipinos with Dual Ctizenstip / Living Abroad__| LI PAMANA Person with Disablity Qsole Proprietor O Foreign National COKIAKIPO — PWOIDNo. Oocroup Enrolment Scheme PRASRRV No. CO Bangsamoro/Normatization ‘ACR E-Card No. For PhilHealth Use only: PROFESSION: Go gr Yaiioniwans [MONTHLY INCOME! [PROOF OF INCOME: ] [Point of Sane (POS) Fanci nena D Financially incapable lis tom may be reprosuced ania ntter sie pamanererPlease check: FROM To [7 ShangeiCorrection of Name (sth FaanRane elon Rae Kane) conection of Date ith i Conection of Sex C1 change of iv status Updating of Personal information/address! D1 Telephone Number/Motile Numberle-mait Acsress Under penalty of law, | hereby attest that the information provided, including the documents | have attached to this form, are true and accurate to the best of my knowledge. | agree and authorize PhilHealth for the subsequent validation, verfication and for other data sharing purposes only under the following circumstances: RECEIVED BY: ‘= As necessary for the proper execution of processes related to the legitimate and declared purpose; ‘= The use or disclosure is reasonably necessary, required or authorized by or under the aw; and, «+ Adequate security messures are employed to protect my information PROLHOPBranch: Date & Time: Preuss afro 41. Allinformation 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 truthfulness and accuracy of all information provided. 3. A property accomplished PMRF shall be accompanied by a valid proof of identity for first time registrants, and supporting documents to establish relationship between member and dependentis for updating or request for amendment. 4. Onthe PURPOSE, check the appropriate box if for Registration or for Undating/Amendment of information. '5. Indicate preferred KonSuTa provider near the place of work or residence. 6. For PERSONAL DETAILS, al name entries should follow the format given below. Check the appropriate box if registrant has no middle name andlor wth single name (mononym). LAST NAME, FIRSTNAME NAME EXTENSION (ir/sr/il) MIDDLE NAME SANTOS JUAN ANDRES m DELA CRUZ 7. Indicate registrant's/member’s name as it appears in the birth certificate. 8. The full mother’s maiden name of registrantmember must be indicated as it appears in the birth certificate. 8. Indicate the full name of spouse if registranvmember is married. 10. Indicate the complete permanent and mailing addresses and contact numbers, 11. For updatinglamendment, check the appropriate box to be updated/amended and indicate the correct data. 12. For MEMBER TYPE, check the appropriate box which best describes your current membership status. 13. For Direct Contributors, except employed, sea-based migrant workers and lifetime members, indicate the profession, monthly income and proof of income to be submitted. 14. For Self-eaming individuals, Kasambahays and Family Drivers, indicate the actual monthly income in the space provided. 15. In declaring dependents, provide the full name of the living spouse, chidren below 21 years old, and parents who are 60 years old 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 PhiHealth coverage for al persons with disability (PWD). 17. The registrant must affix his/her signature over printed name (or right thumbmark if unable to write) and indicate the date when the PMRF was signed.