Republic of the Philippines This form may be reproduced and

PHILIPPINE HEALTH INSURANCE CORPORATION is NOT FOR SALE

*• PhilHealth Citystate Centre 709 Shaw Boulevard. Pasig ( itv

Your Partner in Health

(..’all Center (02) 441-7442 • Trunkline (02) 441-7144
www.philhealth.gov.ph
email: actionCenter^-philhealth.gov.ph
CSF
(Claim Signature Form)
Revised September 2018

IMPORTANT REMINDERS: Series # I ! I I FT"! I F I I 7

PLEASE WRITE IN CAPITAL LETTERS AND CHECK THE APPROPRIATE BOXES
All information required in this form are necessary. Claim forms with incomplete information shal not be processed.
FALSE/INCORRECT INFORMATION OR MISREPRESENTATION SHALL BE SUBJECT TO CRIMINAL, CIVIL OR ADMINISTRATIVE LIABILITIES.

PART I - MEMBER AND PATIENT INFORMATION AND CERTIFICATION

1. PhilHealth Identification Number (PIN) of Member: |l |s [~2 10 11 |8|7|3|8|2|3|- [p~|

2. Name of Member:
PASTRANO RICO ESCASINAS 3. Member Date of Birth:
Lo±d‘~|2|2 I — 1 | 9 | 7 | 6 |
Last Name First Name Middle Name (example: DELA CRUZ JUAN JR SIPAG)
month day year
4. Philhealth Identification Number (PIN) if Dependent:

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

PASTRANO RICO ESCASINAS

Last Name Hrst Name Middle Name (example: DELA CRUZ JUAN JR SIPAG)
7. Confinement Period:
8. Patient Date of Birth

a. Date Admitted: i f | 1 Date Discharged:

month

9. CERTIFICATION OF MEMBER:
Under the penalty of mation I provided form are true and accurate to the best of my knowledge.
p*.', j
Signature Over Printed Name of Member Signature Over Printed Name of Member's Representative
Date Signed
LLJ-
month day year
Date Signed
m-
month day
I’ I
year

If member/ representative is unable to write, Relationship of the

put right thumbmark. MemberZ/Representative representative to the member Sibling | | Others, specify
should be assisted by an HCI representative.
Check the appropriate box Member is incapacitated
Reason for signing on
behalf of the member
Other reasons

PART II - EMPLOYER'S CERTIFICATION (for employed members only)

i.PhilHealth Employer No. (PEN): 2. Contact No.:
3. Business Name:
Business Name of Employer
4. CERTIFICATION OF EMPLOYER:
"This is to certify that the required 3/6 monthly premium contributions plus at least 6 months contributions preceding the 3 months qualifying contributions within 12
months period prior to the first day of confinement (sufficient regularity) have been regularly remitted to PhilHealth. Moreover, the information supplied by the member or
his/her representative on Part I are consistent with our available records."
----------------------------------------------- Date Signed I IF7I - I I I - I
Signature Overprinted Name of Employer / Authorized Representative Official Capacity I Designation-------------------------- —1—1 1—1—1 1—1—1—1—
month day year

PART III - CONSENT TO ACCESS PATIENT RECORD/S

/ hereby cOnStinti to mission and examination of the patient's pertinent medical records for the purpose of verifying the verocrty of this claim to effect efficient
processing of benei
I hereby fiolcf PpilHfi |ny of its officers, employees and/or representatives free from any legal liabilities relative to the herein-mentioned consent which I have
voluntary n in connection with tffis claim for reimbursement before PhilHealth.

Date Signed
Signature Over Printed Name of Member/Authorized Representative

Spouse | | Child
If member/ representative is unable to write, Relationship of the
put right thumbmark. MemberZ/Representative representative to the member Sibling | | Others, specify
should be assisted by an HCI representative.
Check the appropriate box Member is incapacitated
Reason for signing on
behalf of the member
Other reasons

PART IV - HEALTH CARE PROFESSIONAL INFORMATION

Accreditation No.: 11 | 3 | 0 [2j ABELLA, Date Signed 1 I1 L|i |s _ 2 l° I2 3

Sign Over Printed Name month day year

l-LL l-l I I
Accreditation No.: Date Signed
Signature Over Printed Name month day year

Accreditation No.
Signature Over Printed Name
Date Signed
month
|-|

day
J. LL year

PART V - PROVIDER INFORMATION AND CERTIFICATION

1. PhilHealth Benefits : icdio or RVS Code 1. First Case Rate 16010 2.Second Case Rate

/ certify that ed were recorded in the patient's chart and health care institution records and that the herein information given are true and correct

DINAH LES ABELLA, MD. FPOGS, FPCS, CFP.MBA-HHA MEDICAL DIRECTOR Date Signed | |- | j - ■
Signature Over Printed Name Authorized HCI Representative Official Capacity / Designation
month day year