Republic of the Philippines

PHILIPPINE HEALTH INSURANCE

CORPORATION
PMRF
Citystate Centre Building, 709 Shaw Boulevard, Pasig City
PHILHEALTH MEMBER REGISTRATION FORM
(October 2013)
Healthline 441-7444 www.philhealth.gov.ph

PhilHealth Identification Number (PIN)

IMPORTANT REMINDERS:
1. Your PhilHealth Identification Number (PIN) is your unique and permanent number. 1 0 5 1
01 0 0
23. The issuance of the PIN does not. Always use your PIN in all transactions with PhilHealth. automatically qualify you or your dependents to be entitled to NHIP benefits.

1. MEMBER INFORMATION
Last Name First Name Name Extension (JR/SR/III) Middle Name
0
BERNARDO SHARA MAE PURPOSE:
QUIBAN
0
FOR ENROLLMENT FOR UPDATING
If Married Female, please write FULL MAIDEN NAME:
Last Name First Name Name Extension (JR/SR/III) Middle Name

Date of Birth (mm-dd-yyyy) Place of Birth (City/Municipality/Province) Sex Civil Status Nationality Tax Identification No.(TIN)

FILIPINO 315-558-285-000
11-17-1995 SAMPALOC, MANILA
Male Single Widow(er)
Female Married Legally Separated

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

LOT 9 BLOCK 26 NORTHRIDGE

Barangay City/Municipality Province Country Zip Code

STO. CRISTO SAN JOSE DEL MONTE BULACAN PHILIPPINES 3023

Contact Information
Landline Number (Area Code + Tel. No.) Mobile Number E-mail Address

09152646930
[email protected]

2. DECLARATION OF DEPENDENTS (Use separate sheet if necessary)

2.1 Legal Spouse
PhilHealth Identification Name Extension Date of Birth mm- Sex
Number (PIN) Last Name First Name (JR/SR/III) Middle Name dd-yyyy M/F

2.2 Children below 21 years old (unmarried & unemployed) and/or Children 21 years old and above with permanent disability
PhilHealth Identification Name Extension Mark √ if with Date of Birth mm- Sex
Number (PIN) Last Name First Name (JR/SR/III) Middle Name dd-yyyy M/F
Disability

2.3 Parents’ Details

PhilHealth Identification Mark √ if with Date of Birth (mm-dd-
Name Extension
Number (PIN) Father’s Last Name Father’s First Name (JR/SR/III) Father’s Middle Name Permanent yyyy)
Disability
BERNARDO MELANIO III DENONONG / 11-13-1972

PhilHealth Identification Mother’s Full Middle Mark √ if with Date of Birth (mm-dd-
Name Extension
Number (PIN) Mother’s Last Name Mother’s First Name (JR/SR/III)
Name Permanent yyyy)
Disability
QUIBAN MARILOU GURTIZA / 04-19-1972

3. MEMBERSHIP CATEGORY
3. 1 Formal Economy
/ Private Government
3. 3 Indigent
Permanent/Regular Casual Contractor/Project-Based
NHTS-PR
Enterprise Owner
Household Help / Kasambahay
Family Driver
3.2 Informal Economy 3.4 Sponsored
Migrant Worker Local Government Unit (Please specify):
Land Based Sea Based _________________________
Informal Sector (e.g. Market Vendor, Street Hawker, Pedicab/Tricycle Driver, etc.) National Government Agency (Please specify):
(Please specify): _________________________________ ____________________ Others (Please specify):
_____________________________________
 Estimated Monthly Income: Php ________________________
No Income
3.5 Lifetime Member Date/Effectivity of Retirement:
Self-Earning Individual (e.g. Doctors, Lawyers, Engineers, Artists, etc.) Retiree / Pensioner
(Please specify): _________________________________ With 120 months contribution
Estimated Monthly Income: Php ________________________ mm dd yyyy
and has reached retirement age
Filipino with Dual Citizenship
Naturalized Filipino Citizen
Citizen of other countries working/residing/studying in the Philippines
Organized Group (Please specify): _________________________

Please do not write on this portion. For filling-out by PhilHealth Officer:

Under the penalty of law, I attest that the
information I provided in this Form are true
and accurate to the best of my knowledge. Received by: ________________________ Date: ____________

Evaluated by: ________________________ Date: ____________

Please affix right thumbmark if
Signature over Printed Name Date unable to write.

Please carefully read instructions at the back before accomplishing this form.
 INSTRUCTIONS
1.
For PURPOSE, put a mark √ FOR ENROLLMENT if you have never been issued a PhilHealth Identification
Number (PIN) or Family Health Card. Mark √ FOR UPDATING if you want to update or make corrections to
certain information previously submitted when you enrolled. Fill-out the appropriate portions of the form.
2. Please write in CAPITAL LETTERS.
3. ALL FIELDS in item 1 for Member Information ARE MANDATORY. The Member should fill-out all required
information.
4. Write N.A. if the information is not applicable.
All name entries should be in the following format:
5.
Example: JUAN ANDRES DELA CRUZ SANTOS III will be entered as:
Last Name First Name Name Extension Middle Name
SANTOS JUAN ANDRES III DELA CRUZ

6. For the Declaration of Dependents, fill-out the names of the living spouse, children and parents in items 2.1, 2.2
and 2.3 following the same format above.

Put a mark √ in the box for item 2.2 if child has disability.

Put a mark √ in the box for item 2.3 if parent has disability.
Please indicate FULL MOTHER’S NAME for item 2.3.

7.
For declared dependents with disability, please submit a Medical Certificate indicating the details and extent
of disability. As defined in the Implementing Rules and Regulations of the National Health Insurance Act of
2013, the following are included as qualified dependents:

a. Children who are twenty-one (21) years old or above but suffering from congenital disability, either
physical or mental, or any disability acquired that renders them totally dependent on the member for support.

b. Parents with permanent disability regardless of age that renders them totally dependent on the
member for subsistence.

8. For MEMBERSHIP CATEGORY, put a mark √ in the appropriate box and specify details as necessary.
9. The member or guardian (if member is a minor) should certify that the information provided are true and
correct by affixing his/her signature over the printed name in the space provided for. If unable to write,
please affix the right thumbmark in the space provided.