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  • Deactivation Request

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    griever666127
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    This document contains a form from the Philippine Health Insurance Corporation for requesting deactivation of a PhilHealth membership or transferring dependents. The form requests the member's name, PhilHealth number, and reason for either requesting deactivation of their membership or transferring their declared dependents to a spouse, and includes signature lines for the inactive or active member.

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    Philheath Dependent Deactivation

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    This document contains a form from the Philippine Health Insurance Corporation for requesting deactivation of a PhilHealth membership or transferring dependents. The form requests the member's name, PhilHealth number, and reason for either requesting deactivation of their membership or transferring their declared dependents to a spouse, and includes signature lines for the inactive or active member.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    6 views1 page

    Deactivation Request

    Uploaded by

    griever666127
    This document contains a form from the Philippine Health Insurance Corporation for requesting deactivation of a PhilHealth membership or transferring dependents. The form requests the member's name, PhilHealth number, and reason for either requesting deactivation of their membership or transferring their declared dependents to a spouse, and includes signature lines for the inactive or active member.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    Republic of the Philippines

    PHILIPPINE HEALTH INSURANCE CORPORATION


    8007 Pioneer St., Kapitolyo, Pasig City
    Call Call Center: (02) 8441-7442 | Trunkline: (02) 8441-7444
    www.philhealth.gov.ph

    DEACTIVATION REQUEST

    Date: _____________

    Deactivation

    I, ___________________________________, with PhilHealth Number ____________, would like to request


    your good office to please deactivate my said membership due to ______________________________
    (REASON)

    Transfer of Dependent

    I, ___________________________________, with PhilHealth Number ____________, would like to request


    your good office to transfer my declared dependent(s) namely ______________________________________
    to my spouse due to ___________________________________________________
    (REASON)

    Truly yours,

    ________________________________________ ______________________________________________
    (Signature over printed name-INACTIVE Member (Signature over printed name – ACTIVE Member)

    Republic of the Philippines


    PHILIPPINE HEALTH INSURANCE CORPORATION
    8007 Pioneer St., Kapitolyo, Pasig City
    Call Call Center: (02) 8441-7442 | Trunkline: (02) 8441-7444
    www.philhealth.gov.ph

    DEACTIVATION REQUEST

    Date: _____________

    Deactivation

    I, ___________________________________, with PhilHealth Number ____________, would like to request


    your good office to please deactivate my said membership due to ______________________________
    (REASON)

    Transfer of Dependent

    I, ___________________________________, with PhilHealth Number ____________, would like to request


    your good office to transfer my declared dependent(s) namely ______________________________________
    to my spouse due to ___________________________________________________
    (REASON)

    Truly yours,

    ________________________________________ ______________________________________________
    (Signature over printed name-INACTIVE Member (Signature over printed name – ACTIVE Member)

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