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    Deped Cabuyao: (Claim Form 1) Revised November 2013 Series #

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    Wehn Lustre
    1) This document is a PhilHealth claim form that collects information from the patient/member for processing of health insurance claims. 2) It requests identifying information about the patient/member such as name, address, contact details, PhilHealth ID number, as well as date of birth and sex. 3) For dependents, it also asks for the relationship to the member and the member's information.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Deped Cabuyao: (Claim Form 1) Revised November 2013 Series #

    Uploaded by

    Wehn Lustre
    139 views1 page
    1) This document is a PhilHealth claim form that collects information from the patient/member for processing of health insurance claims. 2) It requests identifying information about the patient/member such as name, address, contact details, PhilHealth ID number, as well as date of birth and sex. 3) For dependents, it also asks for the relationship to the member and the member's information.

    Original Description:

    philhealth

    Original Title

    PhilHealth_ClaimForm1 (1)

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    © © All Rights Reserved

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    1) This document is a PhilHealth claim form that collects information from the patient/member for processing of health insurance claims. 2) It requests identifying information about the patient/member such as name, address, contact details, PhilHealth ID number, as well as date of birth and sex. 3) For dependents, it also asks for the relationship to the member and the member's information.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    139 views1 page

    Deped Cabuyao: (Claim Form 1) Revised November 2013 Series #

    Uploaded by

    Wehn Lustre
    1) This document is a PhilHealth claim form that collects information from the patient/member for processing of health insurance claims. 2) It requests identifying information about the patient/member such as name, address, contact details, PhilHealth ID number, as well as date of birth and sex. 3) For dependents, it also asks for the relationship to the member and the member's information.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 1

    This form may be reproduced and is NOT FOR

    SALE CF1
    (Claim Form 1)
    revised
    November 2013
    Series #

    IMPORTANT REMINDERS:
    PLEASE WRITE IN CAPITAL LETTERS AND CHECK THE APPROPRIATE BOXES.
    For local availment, this form together with other PhilHealth claim forms and other supporting documents should be filed within 60 days from date of discharge.
    For availment of benefits abroad, this form together with other supporting documents should be filed within 180 days from date of discharge.
    Representative of the Health Care Institutions (HCI) shall assist the member/authorized representative in filling out this form.
    All information required in this form are necessary. Claim forms with incomplete information shall not be processed.
    FALSE / INCORRECT INFORMATION OR MISREPRESENTATION SHALL BE SUBJECT TO CRIMINAL, CIVIL OR ADMINISTRATIVE LIABILITIES.
    PART I - MEMBER INFORMATION

    1. PhilHealth Identification Number (PIN) of Member


    : - -

    2. Name of Member: 3. Date of Birth: - -


    month day year
    Last Name First Name Name Extension (JR/SR/III) Middle Name (example: DELA CRUZ JUAN JR SIPAG)
    4. Mailing Address: 5. Sex: Male Female

    Unit/ Room No., Floor Building Name Lot/Block/House/Bldg. No. Street Subdivision/Village

    Barangay City/Municipality Province Country Zip Code

    6. Contact information:

    Landline No. (Area Code + Tel. No.): Mobile No.: Email Address:

    7. Patient is the member? Yes, proceed to Part III No, proceed to Part II

    PART II - PATIENT INFORMATION


    (To be filled-out only if the patient is a dependent)

    1
    . PhilHealth Identification Number (PIN) of Dependent : - -

    2. Name of Patient: 3. Date of Birth: - -


    month day year

    Last Name First Name Name Extension (JR/SR/III) Middle Name (example: DELA CRUZ JUAN JR SIPAG
    )

    4. Relationship to Member
    : Child Parent Spouse 5. Sex: Male Female

    PART III - MEMBER CERTIFICATION


    Under the penalty of law, I attest that the information I provided in this Form are true an to the best of my knowledge.

    1 1 0 7 7 4 0 0 0 0 0 4 049-576-3032
    3. Business Name:
    DepEd Cabuyao
    Business Name of Employer
    4. CERTIFICATION OF EMPLOYER:
    This is to certify that all monthly premium contributions for and in behalf of the member, while employed in this company, including the
    applicable three (3) monthly premium contributions within the past six (6) months period prior to the first day of this confinement, have
    been deducted/collected and remitted to PhilHealth, and that the information supplied by the member or his/her representative on Part I
    are consistent with our available records.

    AIDA V. MARAÑA Principal II Date Signed: - -


    Signature Over Printed Name of Employer / Official Capacity / Designation month day year
    Authorized Representative

    PART V - FOR PHILHEALTH USE ONLY

    LHIO
    By:
    PRO LHIO/PRO Signature Over Printed Name

    Date of Received:

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