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This form may be reproduced and is NOT FOR SALE

PHILHEALTH
CLAIM FORM 1
Revised May 2000
Note: This form together with Claim Form 2 should be filed with PhilHealth within 60 calendar days from date of discharge.

PART I - MEMBER'S CERTIFICATION (Member to Fill in All Items/Indigent to be Assisted by Hospital Representative)
1. Type of Membership Employed: Private Sector Gov't. Sector Individually paying: Self-employed OFW Others OWWA
Indigent Retiree/Pensioner: SSS GSIS Military Judiciary
Identification No.

2. Name of Member 3. Date of Birth


Last Name
m m d d y y y y
First Name 4. Civil Status 5. Sex

Single Separated Male


Middle Name
Married Widow/er Female

6. Address of Member
No., Street Barangay

Municipality/City Province Zip Code

7. Name of Spouse
Last Name First Name

Middle Name
Not Applicable

8. Name of Patient Patient is the Member 9. Date of Birth


Last Name
m m d d y y y y
First Name
10. Age 11. Sex
Male
Middle Name
Female
12. Relationship of Patient to Member ( Check applicable box if patient is a dependent )
Legitimate spouse who is not an NHIP Member. Parent who is 60 years old and above, not an NHIP member/retiree/pensioner and
Unmarried and unemployed, legitimate, legitimated, wholly dependent on me for support.
acknowledged and illegitimate or legally adopted/step Unmarried child 21 years old & above with physical/ mental disability, congenital or
child, below 21 years old. acquired and wholly dependent on me for support.
13. CERTIFICATION of MEMBER: I certify that the foregoing information are true and correct and that the three(3) applicable monthly contributions had been
paid within six(6) month prior to the month of this confinement.

Signature of Member Printed Name & Signature of Witness to Thumbmark

If unable to write, affix Right thumbmark


PART II - EMPLOYER'S CERTIFICATION (For employed members only)
14. Registered Name of Employer

Identification No. of Employer


15. Address of Employer ( No., Street, Barangay/Municipality/City, Province, Zip Code )
No., Street Barangay

Municipality/City Province Zip Code

16. CERTIFICATION of EMPLOYER: This is to certify that three(3) applicable monthly contributions were collected during the six(6) month period prior to the
month of this confinement and that the data supplied by the member on Part I are true and conform with our available records.

Signature Over Printed Name of Authorized Representative Date Signed Official Capacity

cut here
Member's Copy This portion should be completely filled up, detached by the hospital and given to member
ACKNOWLEDGEMENT RECEIPT
Name of Member : SSS/GSIS/MEC/PhilHealth No. :
Name of Patient : Confinement Period :
Name of Hospital : PhilHealth Forms Received by :
Address of Hospital : Date :
IMPORTANT

1. For currently employed member, the original and properly accomplished Form 1 is sufficient. In case item no. 16
( Certification of Employer ) is not properly accomplished ( ex. separated from employment, but contribution is still
qualified for the confinement period ) submit RF-1 and ME-5 and/or applicable receipts
2. Beneficiary/Hospital representative to attach the following supporting document/s for:

a) Individually paying ( voluntary, self-employed or OFW members), any of the following:

Official Receipts of PhilHealth accredited collecting banks or PhilHealth Bank Receipts (PBR)
Duly validated MI-5 ( Contributions Payment Return Form ) for individually paying members starting January 2000
Official Receipts issued by PhilHealth ( for over the counter payments )

b) SSS/GSIS Retirees, any of the following:

Latest pension voucher


Copy of bank account passbook ( with pages indicating name of pensioner and latest pension entry )
Retirement Certificate issued by the GSIS/SSS

c) AFP/PNP Retirees, any of the following:

General or Special Orders


Latest pension voucher
Certification of 120 monthly Medicare/NHIP contributions from the GSIS or from previous employer
Service record

d) Retired Judges, any of the following:

Certificate of retirement from the Office of the Court Administration (OCA)


Certification of 120 monthly Medicare/NHIP contributions from the GSIS or from previous employer
Service record

e) SSS partial disability pensioners - certificate from SSS indicating coverage/period of pension

f) Dependents of a, b, c, d and e - approved M1b or E1/E4 for SSS members or

SPOUSE - copy of marriage contract


CHILD - copy of birth or baptismal certificate
Illegitimate/Legitimated child - birth certificate acknowledged by the father/mother or notarized affidavit of support
Legally adopted child - legal adoption paper or notarized affidavit that child is legally adopted
Step-child birth or baptismal certificate with copy of marriage contract or
. .

affidavit by the step-mother or step-father


PARENT - affidavit of support ( original or Certified True Copy )

g) OWWA member/dependent - Certified True Copy of Medicare Eligibility Certificate ( MEC )

Legend:
RF-1 - Quarterly Remittance Report form
ME-5 - Contributions Payment Return form for employed sector
MI-5 - Contributions Payment Return form for individually paying members
M1b - Membership Data Record form for individually paying
E1 - SSS Membership form for new member
E4 - SSS Member's Data Ammendment form
This form may be reproduced and is NOT FOR SALE

PHILHEALTH HEALTH CARE


CLAIM FORM 2 PROVIDER'S CERTIFICATION
Revised May 2000
Note: This form together with Claim Form 1 should be filed with PhilHealth within 60 calendar days from date of discharge.

PART I - HOSPITAL DATA AND CHARGES ( Hospital to Fill in All Items )


1. PhilHealth Accreditation No. 2. Accreditation Category Primary Secondary Tertiary Ambulatory
3. Name of Hospital/Ambulatory Clinic

4. Address of Hospital/Ambulatory Clinic


No., Street Barangay

Municipality/City Province Zip Code

5. Name of Member and Identification


Last Name First Name

Middle Name
Identification No.
6. Address of Member
No., Street Barangay

Municipality/City Province Zip Code

7. Name of Patient 8. Age 10. Admission Diagnosis


Last Name

First Name 9. Sex


M
Middle Name
F
11. Confinement Period m m d d y y y y m m d d y y y y
a. Date Admitted c. Date Discharged e. Claimed No.of Days
AM/PM AM/PM
AM/PM f. Date of Death m m d d y y y y
b. Time Admitted : d. Time Discharged : (If Applicable)
12. Hospital/Ambulatory Services ACTUAL HOSPITAL/ BENEFIT CLAIM
AMBULATORY CHARGES HOSPITAL PATIENT
REDUCTION CODE
a. Room and Board
b. Drugs and Medicines ( Part III for details )
c. X-ray/Lab. Test/Others ( Part IV for details )
d. Operating Room Fee
e. Medicines bought & laboratory performed
outside hospital during confinement period
TOTAL
13. CERTIFICATION of HOSPITAL/AMBULATORY CLINIC: I certify that the services rendered are duly recorded in the patient's chart and that the information
given in this form are true and correct.

Signature Over Printed Name of Authorized Representative Date Signed Official Capacity
PART II - PROFESSIONAL DATA AND CHARGES ( Doctor/s to Fill in Respective Portions )
14. Complete Final Diagnosis
FOR PHILHEALTH USE

Relative Unit Value


15. Case Type Ordinary Intensive Catastrophic
16. Name of Attending Physician Signature & Date Signed Illness Code

17.PHIC Accreditation No. 18. BIR/TIN No. - - Reduction Code


19. Services Performed 20. Actual Benefit Claim
Professional Charges Physician Patient
P P P

21. Name of Surgeon Signature & Date Signed Reduction Code

22.PHIC Accreditation No. 23. BIR/TIN No. - -


24. Services Performed 25. Actual Benefit Claim
Professional Charges Surgeon Patient
P P P
Date of Operation
26. Name of Anesthesiologist Signature&&Date
Signature DateSigned
Signed Reduction Code

27.PHIC Accreditation No. 28. BIR/TIN No. - -


29. Services Performed 30. Actual Benefit Claim
Professional Charges Physician Patient
P P P
NOTE:Anyone who supplies false or incorrect information requested by this or a related form or commits misrepresentation shall be subject to criminal,civil or administrative prosecution
under the law.All data required on this form are necessary for adjudication of the claim.PhilHealth will not adjudicate any claim where forms are not properly or completely accomplished.
PART III - DRUGS AND MEDICINES
Preparation
(cap/sy/inj/tab with Unit Actual Benefit Claim
Generic name Brand ml/mg/gm content) Qty. Price Charges Hospital Patient

1.
2.
3.
4.
5.
6.
7.
8.
9.
10
11.
12.
13.
14.
15.
TOTAL
NOTE: Official Receipts for drugs and medicines purchased by patient must be attached to this claim.
PART IV - X-RAY, LABORATORIES AND OTHERS
Unit Actual Benefit Claim
Particulars Qty. Price Charges Hospital Patient
A. X-ray/Lab.

1.
2.
3.
4.
5.
B. Supplies

1.
2.
3.
4.
5.
C. Others

1.
2.
3.
4.
5.
TOTAL
NOTE: Official Receipts for laboratory procedures performed outside the hospital during this confinement period must be attached to this claim.
PART V - CERTIFICATION of PATIENT/MEMBER
I hereby certify that:
The amount of P was deducted from the hospital charges.
The amount of P was deducted from the professional fee charges.
The amount of P was paid for medicines/lab. acquired outside the hospital during this confinement
( Official Receipts attached ).
No deduction was made from the hospital charges.
No deduction was made from the professional fee charges.

Date Signature Over Printed Name of Patient/Member


This form may be reproduced and is NOT FOR SALE

PHILHEALTH
CLAIM FORM 3 PATIENT'S CLINICAL RECORD
Revised May 2000
Note: This form should be filed with PhilHealth within 60 calendar days from date of discharge.

Case No.:
Admission:
m m d d y y y y AM/PM
Date: Time: :

Name of Hospital/Ambulatory Clinic: Accreditation No.:

Address of Hospital/Ambulatory Clinic:


No., Street Barangay

Municipality/City Province Zip Code

PATIENT'S CLINICAL RECORD


1. Patient Name 2. Age 3. Sex
Last Name Male
Female
First Name 4.

Middle Name
Printed Name & Signature of Admitting Officer
5. Admitting Diagnosis:

6. Chief Complaint:

7. Reason for Admission:

8. Brief History of Present Illness/OB History:

9. Physical Examination ( Pertinent Findings per System )


General Survey:
Vital Signs: BP: HR: RR: Temperature:
HEENT:

Chest/Lungs:

CVS:

Abdomen:

GU ( IE ):

Skin/Extremities:

Neuro Examination:
10. Course in the Wards:

11. Pertinent Laboratory and Pertinent Diagnostic Findings: ( CBC, Urinalysis, Fecalysis, X-ray, Biopsy, etc. )

12. Surgical Operation:

m m d d y y y y AM/PM Printed Name & Signature of Surgeon


Date: Time: :

Type of Anesthesia: Printed Name & Signature of Anesthesiologist

13. Discharge:
m m d d y y y y AM/PM
a. Date: b. Time: :

c. Final Diagnosis:

d. Condition on Discharge:

e. Signature of Attending Physician:

14. Signature or Right Thumbmark of patient or his/her representative:

Printed Name & Signature of Patient or his/her Representative

Right thumbmark
(In case patient and representative could not write) Printed Name & Signature of Witness to Thumbmark
This form may be reproduced and is NOT FOR SALE

PHILHEALTH MATERNITY CARE


CLAIM FORM 4 PACKAGE
April 2003

NOTE: THIS FORM TOGETHER WITH CLAIM FORM 1 SHOULD BE FILED WITH PHILHEALTH WITHIN 60 CALENDAR DAYS FROM DATE OF DISCHARGE.

PART I - FACILITY DATA AND CHARGES ( Facility to Fill in All Items )


1. PhilHealth Accreditation No. 2. Accreditation Category Primary Secondary Tertiary
Non-Hospital Facilities (Lying-in clinics,Midwife-managed clinics,
Birthing Homes,Ambulatory Surgical Clinics)

3. Name of Facility

4. Address of Facility
No., Street Barangay

Municipality/City Province Zip Code

5. Name of Member and Identification


Last Name First Name

Middle Name PhilHealth


Identification No.
6. Address of Member
No., Street Barangay

Municipality/City Province Zip Code

7. Name of Patient 8. Age 9. Admission Diagnosis


Last Name

First Name

Middle Name

10. Confinement Period m m d d y y y y m m d d y y y y


a. Date Admitted b. Date Discharged c. Total No.of Days
d. Date of Death m m d d y y y y
(If Applicable)

11. Facility Services ACTUAL FACILITY BENEFIT CLAIM


CHARGES FACILITY PATIENT REDUCTION CODE

TOTAL
Medicines & Supplies bought & laboratory
performed outside facility during confinement period
12. CERTIFICATION of FACILITY: I certify that the services rendered are duly recorded in the patient's chart and that the information
given in this form are true and correct.

Signature Over Printed Name of Authorized Representative Date Signed Official Capacity
PART II - PROFESSIONAL DATA AND CHARGES (Provider/s to Fill in Respective Portions )
13. Complete Final Diagnosis 14. ICD-10 Code: FOR PHILHEALTH USE

RVS Code

15. Name of Provider Signature & Date Signed Illness Code

16.PHIC Accreditation No. 17. BIR/TIN No. - - Reduction Code


18. Services Performed 19. Actual Benefit Claim
Professional Charges Provider Patient
P P P

NOTE: ANYONE WHO SUPPLIES FALSE OR INCORRECT INFORMATION REQUESTED BY THIS OR A RELATED FORM OR COMMITS MISREPRESENTATION SHALL BE
SUBJECT TO CRIMINAL, CIVIL OR ADMINISTRATIVE PROSECUTION UNDER THE LAW. ALL DATA REQUIRED ON THIS FORM ARE NECESSARY FOR ADJUDICATION OF
THE CLAIM. PHILHEALTH WILL NOT ADJUDICATE ANY CLAIM WHERE FORMS ARE NOT PROPERLY OR COMPLETELY ACCOMPLISHED.
PHILHEALTH MATERNITY CARE
CLAIM FORM 4A PACKAGE
April 2003

NOTE: THIS FORM TOGETHER WITH CLAIM FORM 4 SHOULD BE FILED WITH PHILHEALTH WITHIN 60 CALENDAR DAYS FROM DATE OF DISCHARGE.

Name of Physician/Midwife:
Name of Facility:
Address of Facility:
Name of Patient:

PART I - PRENATAL

INITIAL PRENATAL CONSULTATION (date: ___/___/___)

A. Clinical History and Physical Examination


1. Vital signs are normal
2. Menstrual History LMP : ____________ Menarche: ____________
4. Obstetric History G______ P______ ( ______ ,______ ,______ ,______ )
5. Ascertain 1st Pregnancy was Low-Risk
6. Obstetric risk factors
a. Multiple pregnancy f. History of stillbirth
b. Ovarian cyst g. History of pre-eclampsia
c. Myoma uteri h. History of eclampsia
d. Placenta previa i. Premature contraction
e. History of 3 miscarriages
7. Medical/Surgical Risk Factors
a. Hypertension g. Epilepsy
b. heart disease h. Renal disease
c. Diabetes I. Bleeding disorders
d. Thyroid disorders j. History of previous cesarean section
e. Obesity k. History of uterine myomectomy
f. Moderate to severe asthma
8. Determine pertinent abdominal examinations
a. Abdomen
normoactive bowel sound fundic ht= _______________ Leopold's Maneuver L1: ________ L3: _________
non-tender estimated fetal wt: _________ L2: ________ L4: _________
active fetal movements FHT= __________ presentation: __________________________

b. Speculum Exam c. Internal Exam


parous vagina uterus enlarged to AOG
cervix smooth, closed adnexal masses

9. Give complete diagnosis: _________________________________________________________________________

B. Write Delivery Plan indicating:

1. Orientation to LRMC Package/Availment of Benefits 3. Expected date and venue of delivery


2. Schedule of prenatal examinations Date: ___/___/___ Place: ___________________

FOLLOW-UP PRENATAL CONSULTATION (date: ___/___/___)

Visit No. 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th
Date of visit
A. Determine AOG in weeks
B. Obtain vital signs
a. Wt
b. HR
c. RR
d. BP
e. T

PART II - NORMAL BIRTH (date:__/__/__)


DONE

A. Perform complete Physical Examination (VS)

1. Determine AOG AOG: ___________ LMP: ___________

2. Obtain Vital Signs HR: _____ RR: _____ BP: _____ T: ____

3. Perform pertinent physical examination

a. HEENT b. Heart/Lungs c. Skin/Extremities


anicteric sclerae (+) (-) clear breath sounds (+) (-) full pulses (+) (-)
pink palpebral conjunctiva (+) (-) sinus rhythm (+) (-) bipedal edema (+) (-)
REMARKS _______________ REMARKS _______________ REMARKS _______________
4. Determine pertinent abdominal examinations
regular uterine contractions (+) (-) FHT= __________
bloody show (+) (-) fundic ht= _______________
active fetal movements (+) (-) estimated fetal wt: _________

5. Perform IE
BOW:__________________ Cervical Effacement: _______________ Presentation: ____________
Cervical dilatation: ___________________ Station: ________________

B. Ascertain that patient is in true active labor Time of start of labor:

C. Admit and obtain informed consent Time of Admission:

D. Monitor course of labor, accomplish partogram

E. Prepare Delivery Room

F. Attend to Delivery of Baby Time of delivery of newborn:

G. Get APGAR score of Newborn APGAR :

H. Routine Newborn Care

I. Perform Delivery of Placenta Time of delivery of placenta:

J. Check if placenta is complete

K. Ensure good uterine contraction

L. Inspect for perineal and vaginal lacerations

M. Explain to patient the procedure of perineal repair

N. Suture perineal laceration under Local Anesthesia

O. Check repair and ensure hemostasis

P. Transfer patient to recovery area

Q. Monitor during Immediate Postpartum Period BP: ____ HR: ____RR: ____T: ____

R. Discharge Clearance (D/C IE) Vagina:


Cervix:
Uterus:

S. Give Complete Diagnosis

OB Score : G ____ P ____ ( ____ , ____ , ____ , ____ )

Maternal Outcome: _________________ , _________________ , _________________ , ________________


Pregnancy Uterine AOG by LMP Manner of Delivery Presentation

Birth Outcome: ____________ , ____________ , ____________ , ____________


Live Sex Birthweight APGAR Score

T. Accomplish documents for PHIC Reimbursement

U. Schedule Postpartum and Newborn Care follow-up Date: ______________________

consult - 1 week after delivery

V. Discharge Patient Date and Time of Discharge: ______________________


PHILHEALTH MATERNITY CARE
CLAIM FORM 4B PACKAGE
April 2003

NOTE: THIS FORM TOGETHER WITH CLAIM FORM 4 SHOULD BE FILED WITH PHILHEALTH WITHIN 90 CALENDAR DAYS FROM DATE OF DISCHARGE.
Name of Physician/Midwife:
Name of Facility:
Address of Facility:
Name of Patient:

POST-PARTUM CARE (date:__/__/__)

DONE REMARKS

A. Check perineal wound healing

B. Check for signs of Maternal Postpartum complications

C. Check for signs of Newborn complications

D. Counselling and Education

1. Newborn Care

2. Breastfeeding and Nutrition

3. Newborn Immunization

4. Family Planning

E. Provide family planning service to patient if requested

F. Refer to Partner Physician for Voluntary Surgical Sterilization, if requested by patient

G. Schedule postpartum visit 6 weeks postpartum


PHILHEALTH TB-DOTS PACKAGE
March 2003 CLAIM FORM 5

NOTE: THIS FORM TOGETHER WITH CLAIM FORM 1 SHOULD BE FILED WITH PHILHEALTH WITHIN 60 CALENDAR DAYS FROM DATE OF COMPLETION OF TREATMENT

1. PhilHealth Accreditation No.

2. Name of Hospital/DOTS Center

3. Address of Hospital/DOTS Center


No., Street Barangay

Municipality/City Province Zip Code

4. Name of Member
Last Name PIN

First Name

Middle Name

5. Address of Member
No., Street Barangay

Municipality/City Province Zip Code

6. Name of Patient 7. Age 9. Date of Registration Enrollment:


Last Name Date of Completion:

First Name 8. Sex intensive phase date of death

M
Middle Name maintenance
F

10. Diagnosis and ICD-10 Code:

11. CLASSIFICATION OF TB: 12. CATEGORY (tick box):


Pulmonary I. 6-SCC (2HRZE/4HR) II. 8-CC (2HRZES/5HRE)
Extra-Pulmonary site: _______________ New Case 1.Relapse 2.Failure
1. Smear (+) 3. Return After Default (RAD) 4. Other (smear +)
TYPE OF PATIENT: 2. Seriously ill III. 6-SCC (2HRZ/4HR)
New Return After Default (RAD) 2.1. Smear (-): MA or FA New Case
Relapse Failure Radiographic lesion 1. Smear (-): Minimal
Trans. In Other 2.2. Extra-pulmonary 2. Extra-pulmonary not seriously ill

13.CERTIFICATION of HOSPITAL/DOTS CENTER: I certify that the services rendered are duly recorded in the patient's chart and that the information
in this form are true and correct.

Signature Over Printed Name of Authorized Representative Date Signed Official Capacity