PhilHealth forms

Member registration, employer reports and claim forms. 342 forms, sorted by form number.

• Annex “ C 1 – RF/RHD ”Tranche 1
• Annex “ C 2 – RF/RHD ”Tranche 2
• Annex “ E 2 – ALL ”Same as patient (Answer the following only if the patient is a
• CF-1Claim Form 1
• CF-2Claim Form 2
• CF-3Claim Form 3: Patient's Clinical Record
• CF-4Claim Form 4
• —After last cycle of Chemotherapy
• —Amount after Patient Information Member Information Sub-groups of application
• —Annex
• —Annex “ A – Developmental Disability ”
• —Annex “ A – Hearing Impairment ”
• —Annex “ A – RF/RHD ”
• —Annex “ A – Visual Disabilities ”
• —Annex “ C – Developmental Disability ”
• —Annex “ C 1 – Developmental Disability ”
• —Annex “ C 1 – Hearing Impairment ”
• —Annex “ C 1.1 – Visual Disabilities ”
• —Annex “ C 1.2 – Cervical CA ”
• —Annex “ C 1.2 – Visual Disabilities ”
• —Annex “ C 1.3 – Cervical CA ”
• —Annex “ C 1.3 – Visual Disabilities ”
• —Annex “ C 2 – ALL ” Checklist of Mandatory and Other Services Acute
• —Annex “ C 2 – Developmental Disability ”
• —Annex “ C 2 – Hearing Impairment ”
• —Annex “ C 2.1 – Visual Disabilities ”
• —Annex “ C 2.2 – Visual Disabilities ”
• —Annex “ C 2.3 – Visual Disabilities ”
• —Annex “ C 3 – ALL ”
• —Annex “ C 3 – Hearing Impairment ”
• —Annex “ C.3 – Visual Disabilities ”
• —Annex “ C.4 – Visual Disabilities ”
• —Annex " E – Developmental Disability ”
• —Annex " E – RF/RHD ”
• —Annex “ E 3 – ALL ”
• —Annex " E 3.3 – Visual Disability ”
• —Annex " E.4 – Visual Disability ”
• —Annex " E1 – Developmental Disability ”
• —Annex " E1 – Hearing Impairment ”
• —Annex " E1.1 – Visual Disability ”
• —Annex " E1.2 – Visual Disability ”
• —Annex " E2 – Developmental Disability ”
• —Annex " E2 – Mobility Impairment”
• —Annex " E2.1 – Hearing Impairment ”
• —Annex " E2.1 – Visual Disability ”
• —Annex " E2.2 – Visual Disability ”
• —Annex " E2.3 – Visual Disability ”
• —Annex " E3 – Mobility Impairment”
• —Annex " E3.1 – Hearing Impairment ”
• —Annex " E3.1 – Visual Disability ”
• —Annex " E3.2 – Visual Disability ”
• —Annex “ G – RF/RHD ”
• —Annex “ H ” Transmittal Form of Claims for the Outpatient Benefits for RF/RHD
• —Annex “ J – Hearing impairment ”
• —Annex “ J – Visual Disabilities ”
• —Annex “ K – Hearing impairment ”
• —Annex “ M – RF/RHD ” Checklist for Patient Transfer Rheumatic Fever/Rheumatic Heart
• —Annex “A – Cervical CA”
• —Annex “A – Mobility Impairment ”
• —Annex "B -ME Form"
• —Annex “C – Prostate CA”
• —Annex “C1.1 – Cervical CA”
• —Annex "E – Mobility Impairment”
• —Annex "E – Prostate CA”
• —Annex "E1 – Mobility Impairment”
• —Annex "E1.1 – Cervical CA”
• —Annex "E1.2 – Cervical CA”
• —Annex "E1.3 – Cervical CA”
• —Annex “F - RF/RHD”
• —Annex “F – Visual Disabilities”
• —Annex “J – Mobility Impairment”
• —Annex A – “Prostate CA”
• —Annex A 1: Preauthorization Checklist -Colon CA
• —Annex A 2: Preauthorization Checklist -Rectal CA
• —Annex A: Agreement Form
• —Annex A: Checklist of Eligibility Criteria
• —Annex A: Checklist of Eligibility Criteria for Physical Medicine and Rehabilitation
• —Annex A: Pre -authorization Checklist and Request Form
• —Annex A: ZMORPH Pre-authorization Checklist and Request
• —Annex A.1: Checklist of Eligibility Criteria for Diagnostic Tests and Prognostication –
• —Annex A.1: Checklist of Eligibility Criteria for Peritoneal Dialysis - Adult
• —Annex A.1: EMORPH Pre -Authorization Checklist: Upper and Lower Limb Prosthesis
• —Annex A.1: Pre -authorization Checklist and Request for Coronary Artery Bypass Graft
• —Annex A.1: Pre -authorization Checklist and Request Form for Heart Valve Replacement
• —Annex A.1: Pre authorization Checklist and Request for Hip Arthroplasty
• —Annex A.2: Checklist of Eligibility Criteria for Peritoneal Dialysis - Pediatric
• —Annex A.2: EMORPH Pre -Authorization Checklist: Lower Limb Orthosis
• —Annex A.2: Pre -authorization Checklist and Request for Closure of Ventricular Septal
• —Annex A.2: Pre -authorization Checklist and Request Form – Breast Cancer
• —Annex A.2: Pre authorization Checklist and Request for Hip Fixation
• —Annex A.3: EMORPH Pre -Authorization Checklist: Spinal Orthosis
• —Annex A.3: Pre -authorization Checklist and Request for Tetralogy of Fallot (TOF) or
• —Annex A.3: Pre authorization Checklist and Request for Pertrochanteric Fractures
• —Annex A.4: Health Facilities Standards
• —Annex A.4: Pre authorization Checklist and Request for Femoral and Tibial Shaft Fractures
• —Annex A.5: Pre authorization Checklist and Request for Total Knee Replacement
• —Annex A.6: Pre authorization Checklist and Request for Upper Extremities
• —Annex B: Certificate Of Renal Replacement Therapy Add -on Service For Patients With
• —Annex B: Member Empowerment Form
• —Annex B: Member Empowerment Form
• —Annex B: Member Empowerment Form
• —Annex B: Member Empowerment Form
• —Annex B: Patient Registry Matrix
• —Annex B.1 Health Human Resource Survey Tool for PhilHealth Konsulta Provider
• —Annex B.3 Checklist of PhilHealth Konsulta Laboratories
• —Annex C 3.1: Rectal Cancer Pre -Operative Clinical Stage I with Post -Operative
• —Annex C: Certificate Of Invasive Or Non -Invasive Ventilatory Support As Add -On Service
• —Annex C: Member Empowerment Form
• —Annex C: ZMORPH Discharge Checklist
• —Annex C.1: Checklist of Mandatory and Other Services for Diagnostics and Prognostication
• —Annex C.1: Discharge Checklist for the Z Benefits (Tranche 1)
• —Annex C.1: Pre -authorization Checklist and Request Form for Wheelchairs
• —Annex C.1.1: EMORPH Discharge Checklist: Lower Limb Prosthesis
• —Annex C.1.2: EMORPH Discharge Checklist: Upper Limb Prosthesis
• —Annex C.1.3: EMORPH Discharge Checklist: Lower Limb Orthosis
• —Annex C.1.4: EMORPH Discharge Checklist: Spinal Orthosis
• —Annex C.2: Checklist of Mandatory and Other Services - Premature Small Baby
• —Annex C.2: Checklist of Mandatory and Other Services for Surgery
• —Annex C.2: Discharge Checklist for the Z Benefits (Tranche 2)
• —Annex C.2: EMORPH Discharge Checklist (Tranche 2)
• —Annex C.2: Pre -authorization Checklist and Request Form for other Assistive Mobility
• —Annex C.3: Checklist of Mandatory and Other Services for Chemotherapy
• —Annex C.4.1: Checklist of Mandatory and Other Services for Hormonotherapy Tranche 1
• —Annex C.4.2: Checklist of Mandatory and Other Services for Hormonotherapy Tranche 2
• —Annex C.5.1: Checklist of Mandatory and Other Services for Targeted Therapy - Tranche 1
• —Annex C.5.2: Checklist of Mandatory and Other Services for Targeted Therapy - Tranche 2
• —Annex C.5.3: Checklist of Mandatory and Other Services for Targeted Therapy - Tranche 3
• —Annex C.6: Checklist of Mandatory and Other Services for Surveillance
• —Annex C1 – ALL: Checklist of Mandatory and Other Services, Acute Lymphocytic/Lymphoblastic Leukemia (Standard Risk)
• —Annex C1.1: Colon Cancer Stage I to II (low risk) – Post -surgery
• —Annex C1.2: Colon Cancer Stage II (high risk) to III – Post -surgery
• —Annex C1.3: Colon Cancer Stage II (high risk) to III – After last cycle of Chemotherapy
• —Annex C2.1: Rectal Cancer Stage I (clinical and pathologic stage) – Post -surgery
• —Annex C3.2: Rectal Cancer Pre -Operative Clinical Stage I with Post -operative
• —Annex C3.3: Rectal Cancer Pre -Operative Clinical Stage I with Post -operative
• —Annex C4.1: Rectal Cancer Pre -treatment Clinical Stage II to III – After
• —Annex C4.2: Rectal Cancer Pre -treatment Clinical Stage II to III – Post -surgery
• —Annex C4.3: Rectal Cancer Pre -treatment Clinical Stage II to III – After last cycle of
• —Annex D: Certificate of Pulmonary Rehabilitation Add -on Service For Patients
• —Annex D: Member Empowerment (ME Form)
• —Annex D: Member Empowerment Form
• —Annex D: Member Empowerment Form (ME Form)
• —Annex D: Mental Health Passport
• —Annex D: Peritoneal Dialysis (PD) Passport
• —Annex D: Waiver for Directly Filed SARS-CoV-2 Test Claims
• —Annex D: Waiver for Directly Filed SARS-CoV-2 Test Claims (second file)
• —Annex D: Z Satisfaction Questionnaire
• —Annex E: At-Risk Classification and SARS-CoV-2 Test Charges
• —Annex E: At-Risk Classification and SARS-CoV-2 Test Charges (second file)
• —Annex E: Checklist of Essential Health Services
• —Annex E: Letter of Intent for the Transfer of MH Care to a Referral MH Provider
• —Annex E: Letter of Intent for Transfer of PD Care
• —Annex E: ZMORPH Checklist of Requirements for Reimbursement
• —Annex E.1: Checklist of Requirements for Reimbursement – Diagnostic Test and
• —Annex E.1: Checklist of Requirements for Reimbursement (Tranche 1)
• —Annex E.1: EMORPH Tranche 1 Requirements for Reimbursement
• —Annex E.1.: Checklist of Essential Health Services - Kidney Transplant Recipient
• —Annex E.1.: Checklist of Essential Health Services - Kidney Transplant Recipient - Adult
• —Annex E.2: Checklist of Requirements for Reimbursement - Premature Small Baby
• —Annex E.2: Checklist of Requirements for Reimbursement – Surgery
• —Annex E.2: Checklist of Requirements for Reimbursement (Tranche 2)
• —Annex E.2: EMORPH Tranche 2 Requirements for Reimbursement
• —Annex E.2.: Checklist of Essential Health Services - Living Kidney Donor
• —Annex E.3: Checklist of Requirements for Reimbursement – Chemotherapy
• —Annex E.4.1: Checklist of Requirements for Reimbursement – Hormonotherapy Tranche 1
• —Annex E.4.2: Checklist of Requirements for Reimbursement – Hormonotherapy Tranche 2
• —Annex E.5.1: Checklist of Requirements for Reimbursement – Targeted Therapy Tranche 1
• —Annex E.5.2: Checklist of Requirements for Reimbursement – Targeted Therapy Tranche 2
• —Annex E.5.3: Checklist of Requirements for Reimbursement – Targeted Therapy Tranche 3
• —Annex E.6: Checklist of Requirements for Reimbursement – Surveillance
• —Annex E1.1: Colon Cancer Stage I to II (low risk) – Post -surgery
• —Annex E1.2: Colon Cancer Post -Surgery Stage II (high risk) to III – Post -surgery
• —Annex E1.3: Colon Cancer Stage II (high risk) to III – After completion of Chemotherapy
• —Annex E2.1: Rectal Cancer Stage I (clinical and pathologic stage) – Post -surgery
• —Annex E3.1: Rectal Cancer Pre -Operative Clinical Stage I with Post -Operative
• —Annex E3.2: Rectal Cancer Pre -Operative Clinical Stage I with Post -operative
• —Annex E3.3: Rectal Cancer Pre -Operative Clinical Stage I with Post -operative
• —Annex E4.1: Rectal Cancer Pre -treatment Clinical Stage II to III – After completion of
• —Annex E4.2: Rectal Cancer Pre-treatment Clinical Stage II to III: Post-surgery
• —Annex F: Breast Cancer Treatment Passport
• —Annex F: Checklist for Patient Transfer
• —Annex F: Checklist for Patient Transfer - PD Z Benefits
• —Annex F: Checklist of Requirements for Reimbursement
• —Annex F: Checklist of Requirements for Reimbursement (Benefits)
• —Annex F: Post-Kidney Transplant Passport
• —Annex F: Post-Kidney Transplant Passport
• —Annex F: Self -Assessment Tool for Zmorph and Expanded Zmorph
• —Annex F: Self -Assessment/Survey Tool
• —Annex F.1: Checklist of Requirements for Reimbursement - Assessment
• —Annex F.1.: Checklist of Requirements for Reimbursement for Open Heart Surgery
• —Annex F.2: Checklist of Requirements for Reimbursement - Rehabilitation Services
• —Annex F.2.: Checklist of Requirements for Reimbursement for
• —Annex F.3: Checklist of Requirements for Reimbursement - Laboratory and
• —Annex F.4: Checklist of Requirements for Reimbursement - Assistive Mobility Devices
• —Annex G Kidney Transplantation Data Registry
• —Annex G: Checklist for Patient Transfer
• —Annex G: Transmittal Form
• —Annex G: Transmittal Form
• —Annex G.1A: Checklist of Requirements for Reimbursement Using CAPD - Adult
• —Annex G.1B: Checklist of Requirements For Reimbursement - Exit Site Infection
• —Annex G.2A: Checklist of Requirements for Reimbursement Using CAPD - Pediatric
• —Annex G.2B: Checklist of Requirements for Reimbursement Using APD - Pediatric
• —Annex G.2C: Checklist of Requirements For Reimbursement - Exit Site Infection
• —Annex G.3 A: Checklist of Requirements For Reimbursement – PD -related Ancillary Services
• —Annex G.3 B: Checklist of Requirements For Reimbursement – PD -related Ancillary Services
• —Annex G.3 C: Checklist of Requirements for Reimbursement – PD -related Ancillary Services
• —Annex H: Checklist for Patient Transfer to a Contracted HF
• —Annex H: Checklist for Patient Transfer to the Referral Contracted HF
• —Annex H: Checklist of Essential Health Services
• —Annex H: Checklist of Essential Health Services for Kidney Transplantation
• —Annex H: Transmittal Form for Claims Application
• —Annex H: Transmittal Form of Claims for the Z Benefits
• —Annex H: Transmittal Form of Claims for the Z Benefits
• —Annex H: Transmittal Form of Claims for the Z Benefits
• —Annex H.1: Checklist of Essential Health Services for Coronary Artery Bypass Graft (CABG)
• —Annex H.2: Checklist of Essential Health Services for Closure of Ventricular Septal
• —Annex H.3: Checklist of Essential Health Services for Tetralogy of Fallot (TOF) or
• —Annex H.4: Checklist of Essential Health Services for Post -Cardiac Surgery Services
• —Annex I: Letter of Intent for Transfer to a Contracted Health Facility
• —Annex I: Outcomes Report Form for Colon and Rectal Cancers
• —Annex I: Pilot Testing of the Rehabilitation and Mobility Devices Package
• —Annex I: Transmittal Form of Claims For the Z Benefits
• —Annex I: WHO Partograph
• —Annex I.1A: Checklist of Essential Health Services Using CAPD - Adult
• —Annex I.1B: Checklist of Essential Health Services for Exit Site Infection and
• —Annex I.2: Checklist of Requirements For Reimbursement - Living Kidney Donor
• —Annex I.2: Checklist of Requirements Reimbursement - Living Kidney Donor
• —Annex I.2A: Checklist of Essential Health Services Using CAPD PD Bags - Pediatric
• —Annex I.2B: Checklist of Essential Health Services Using APD PD Bags - Pediatric
• —Annex I.2C: Checklist of Essential Health Services for Exit Site Infection and Peritonitis
• —Annex I.3A: Checklist of Essential Health Services for PD Catheter Insertion and
• —Annex I.3B: Checklist of Essential Health Services for Outpatient Treatment of PD
• —Annex I.3C: Checklist of Essential Health Services for Laboratory/Diagnostic Tests and
• —Annex J: Transmittal Form
• —Annex J: Transmittal Form
• —Annex J.1: Checklist of Mandatory and Other Services – Tranche 1 As of October 202 3
• —Annex J.2: Checklist of Mandatory and Other Services – Tranche 2 As of October 202 3
• —Annex J.3: Checklist of Mandatory and Other Services – Tranche 1 As of October 202 3
• —Annex J.4: Checklist of Mandatory and Other Services – Tranche 2 As of October 202 3
• —Annex K: Mental Health Satisfaction Questionnaire As of October 202 3
• —Annex K: Transmittal Form of Claims For the PD Z Benefits
• —Annex K: Z Satisfaction Questionnaire
• —Annex K: Z Satisfaction Questionnaire
• —Annex L: Home Visitation Questionnaire For PD Z Benefits Package
• —Annex L.1: Checklist of Requirements for Reimbursement – Tranche 1
• —Annex L.2: Checklist of Requirements for Reimbursement – Tranche 2
• —Annex L.3: Checklist of Requirements for Reimbursement – Tranche 1
• —Annex L.4: Checklist of Requirements for Reimbursement – Tranche 2
• —Annex M: Breast Cancer Medical Records Summary Form
• —Annex M.2: Post Mortem Care, Bereavement Support and Counselling Services Checklist
• —Annex N: Certificate of Medical Futility
• —Annex O: Indicators for Medical Futility
• —Annex P: Other High-Risk Conditions of Pregnant Women
• —Antenatal Care Record
• —As of October 2023
• —Assessment Checklist of Clinical and Social Criteria for Covid -19 Home
• —Certificate of Assessment and Recommendations
• —Checklist of Mandatory Services
• —Checklist of Mandatory Services Z Benefits for Children with Mobility Impairment
• —Checklist of Mandatory Services Z Benefits for Hearing Impairment
• —Checklist of Requirements for Reimbursement Kidney Transplant Recipient - Pediatric
• —Checklist of Requirements for Reimbursement Kidney Transplant Recipient Adult
• —Chronic Kidney Disease - (CKD) stage 5
• —Claim Signature Form
• —Clinical Pathway: The Rheumatic Fever Suspect
• —Coordinated Referral and Transfer Form
• —Direction: Please check appropriate box Requirements HCI Phic Remarks
• —Employer Data Record
• —Employer’s Remittance Report for PhilHealth Use
• —ER3
• —Essential Intrapartum and Newborn Care (EINC) Protocol Checklist
• —Field Survey Tool
• —Hci / Rhu Information
• —Household Employer Unified Registration Form (PPS-HEUR1)
• —Household Employment Unified Report Form (PPS-HEUR2)
• —Kangaroo Care Protocol Checklist
• —Kasambahay Unified Registration Form (PPS-KUR)
• —Letter of Intent to Transfer Post-Transplant Care (Adult)
• —Letter of Intent to Transfer Post-Transplant Care (Child)
• —Letter of Undertaking as Provider of the Expanded Maternity Care Benefits
• —Letterhead of the referral facility
• —Letterhead of the referral facility Logo Certification of Service Delivery Support
• —Living Kidney Donor Pre-Authorization (Adult Recipient)
• —Living Kidney Donor Pre-Authorization (Child Recipient)
• —Mandatory Services Checklist — Children with Mobility Impairment
• —Name & Signature Date of Therapy Sessions Name & Signature Date of MD of Patient/
• —National RF /RHD Registry
• —Non- Disclosure Agreement
• —Non-Disclosure Agreement
• —Non-Disclosure Agreement for PhilHealth Employer's Engagement Representative (PEER)
• —Non‑Disclosure Agreement
• —Performance Commitment for Health Care Professionals (Rev. 3)
• —PhilHealth Account & Cipher Key Request Form
• —PHILHEALTH Dialysis Database Registration Form
• —PhilHealth Employers’ Engagement Representative (Peer)
• —PhilHealth HCI Engagement Registration
• —PhilHealth Member Registration Form
• —PhilHealth Member Registration Form for Foreign National
• —PhilHealth Online Access Form
• —PhilHealth Premium Payment Slip
• —PhilHealth Premium Payment Slip
• —Postpartum Care Record
• —Pre -authorization Checklist and Request Form for Heart Valve Repair and /or Replacement
• —Pre-Authorization Checklist and Request Form for Kidney Transplant Recipient Adult
• —Pre-Authorization Checklist and Request Form for Kidney Transplant Recipient Pediatric
• —Pre-Discharge Counselling Services Checklist
• —Pre‑Authorization Checklist – Acute Lymphocytic/Lymphoblastic Leukemia Standard Risk
• —Preterm Delivery Prevention — Mandatory Services Checklist
• —Preterm Delivery Prevention — Reimbursement Requirements Checklist
• —Provider Data Record (PDR) for Health Facilities (HFs)
• —Provider Data Record Health Care Professionals
• —Reimbursement Checklist (Annex E1 – ALL)
• —Report of Employee-Members
• —Rheumatic Fever /
• —Rheumatic Fever/ Rheumatic Heart Disease
• —Self - assessment/ Survey Tool for Z Benefit Package Providers for Peritoneal Dialysis
• —Self -assessment / Accreditation Survey Tool PhilHealth YAKAP Provider
• —Self -assessment / Survey Tool for Benefit Package Providers for Physical Medicine
• —Self -assessment / Survey Tool for the Outpatient Benefits Package for General Mental
• —Self -assessment / Survey Tool for Z Benefit Package for Heart Valve Repair
• —Self -assessment / Survey Tool for Z Benefit Package for Kidney Transplant (KT)
• —Self -assessment / Survey Tool for Z Benefit Package for Post - Kidney Transplantation
• —Self -Assessment /Survey Tool for Z Benefit Package Providers for Colon and Rectum Cancers
• —Self -Assessment/Survey Tool for Outpatient Benefit Package for Severe Acute Malnutrition
• —Self -Assessment/Survey Tool for Z Benefit Package Providers for Breast CA (Stage O to IV)
• —Self -assessment/Survey Tool for Z Benefit Package Providers for Selected Orthopedic
• —Self- assessment/ Survey Tool for Z benefit Package Providers for Cervical Cancer
• —Self- Assessment/Survey Tool for Z Benefit Package Providers for Children with
• —Self-Assessment Survey Tool for Z Benefit Package for Open Heart Surgeries (CABG & VHD*)
• —Self-Assessment Survey Tool for Z Benefit Package for Open Heart Surgeries (VSD/TOF/VHD*)
• —Self-assessment tool for Z Benefit Package for Acute Lymphocytic Leukemia
• —Self-Assessment/ Survey Tool for Z Benefit Package Providers for Children with
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• —Software Certification Agreement
• —Software Certification Application Form
• —Z Benefit Self-Assessment — Adult Post-Kidney Transplant Services
• —Z Benefit Self-Assessment — Children with Developmental Disabilities