ANNEX A

Name of Facility: ___________________________________________

Address: _________________________________________________
PhilHealth Accreditation Number: _______________________________

YEAR SUMMARY OF ACCOUNT RECEIVABLE PER CALENDAR YEAR

NO YES CLAIMS COUNT AMOUNT
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
TOTAL
Note: Place an "X" mark on the applicable items.

Prepared by: Certified Correct by:

Designation Chief Accountant

(Signature over printed name) (Signature over printed name)

Certified Correct by:

Medical Director/Chief of Hospital/Owner

(Signature over printed name)
[HOSPITAL NAME] ANNEX B
[HOSPITAL CODE]
[Address]
REPORT OF UNPAID CLAIMS - ACCOUNT RECEIVABLE
As of ________________

YEAR (start Patient Name Member Name

Item Claim Series Member's Date of Admission Date Discharged Date Filed Date Refiled Case Rate/ ICD 10/RVS *Claim
from
No. Number PIN (mm/dd/yyyy) (mm/dd/yyyy) (mm/dd/yyyy) (mm/dd/yyyy) Claim Amount Code Status
current)
Surname First Name Middle Name Surname First Name Middle Name

*Claim Status: In process, Return to Hospital (RTH), Denied, Filed under MR or under Appeal

Prepared by: Certified Complete and Accurate by: Approved by:

Chief Accountant Medical Director/Chief of Hospital

[HOSPITAL NAME] ANNEX C
[HOSPITAL CODE]
[Address]
REPORT OF UNSUBMITTED CLAIMS - IBNR
As of ________________

YEAR (start Patient Name Member Name

Item Claim Series Member's Date of Admission Date Discharged Case Rate/ Claim
from ICD 10/RVS Code *Claim Status
No. Number PIN (mm/dd/yyyy) (mm/dd/yyyy) Amount
current)
Surname First Name Middle Name Surname First Name Middle Name

Prepared by: Certified Complete and Accurate by: Approved by:

Chief Accountant Medical Director/Chief of Hospital