Cf1 Form PDF Details

In the landscape of health care and insurance, paperwork stands as the bridge between receiving services and ensuring these services are appropriately recorded and reimbursed. Among these crucial documents is the CF1 form, a tool designed not only for record-keeping but as a means of navigating the intricacies of health insurance claims. Revised in February 2010, this document embodies an essential process for individuals seeking coverage for medical confinement, either locally or abroad. It mandates the use of capital letters for clarity, stresses the importance of timely submissions—60 days for local and 180 days for international cases—and emphasizes the filing of original documents to facilitate claims. This form, which is not for sale and can be freely reproduced, is comprehensive, requiring detailed member and patient information, and it leaves no room for ambiguity regarding the consequences of furnishing false or incorrect data, warning of potential criminal, civil, or administrative liabilities for such actions. Moreover, it integrates a certification process involving both the member (or their representative) and, for employed members, the employer, ensuring a double layer of verification to maintain the integrity and accuracy of the information provided. In essence, the CF1 form stands as a testament to the structured yet flexible framework designed to support individuals through the maze of health insurance claims, balancing the need for thorough documentation with the practical aspects of user accessibility and legal compliance.

QuestionAnswer
Form NameCf1 Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesphilhealth form cf1, cf1, cf1 form, cf1 form 2020 pdf

Form Preview Example

This form may be reproduced and is NOT FOR SALE

CF1

(Claim Form) revised February 2010

IMPORTANT REMINDERS:

PLEASE WRITE IN CAPITAL LETTERS AND CHECK THE APPROPRIATE BOXES.

For local confinement, this form together with CF2 and other supporting documents should be filed within60 DAYS from date of discharge. For confinement abroad, this form together with other supporting documents should be filed within180 DAYS from date of discharge. Only one (1) original copy of this Form is required per claim application/availment.

All information required in this form are necessary and 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 and PATIENT INFORMATION

(Member/Representative to fill out all items with the assistance of the Health Care Provider)

1. PhilHealth Identification No. (PIN):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2. Member Category:

 

 

3. Name of Member

Last Name

First Name

Middle Name

( example : Dela Cruz, Juan Jr., Sipag)

Employed

Government

Private

Individually

Paying

Sponsored

OFW

Lifetime

4. Mailing Address:

 

 

 

 

 

 

5. Date of Birth:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(House Number & Name of Street)

 

(Barangay)

 

 

 

(Month)

(Day)

(Year)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(City / Municipality)

(Province)

(ZIP Code)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6.

Contact Information (if available):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E-mail Address:

 

Mobile No.:

 

 

 

 

 

Landline No.:

 

 

 

 

 

7.

Name of Patient:

 

 

 

8.

 

Patient is the Member

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient is a Dependent

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last Name

First Name

Middle Name

( example: Dela Cruz, Juan Jr., Sipag)

9.CERTIFICATION OF MEMBER:

Child

Spouse

Parent

I hereby certify that the herein information are true and correct and may be used for any legal purpose.

Signature Over Printed Name of Member

Date Signed (month-day-year)

11.Reason for Signing on Behalf of the Member:

Member is Abroad / Out-of-Town

Signature Over Printed Name of Member's Representative

10.Relationship of the Representative to the Member:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Child

 

Parent

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date Signed (month-day-year)

 

 

Spouse

 

Guardian / Next

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Member is Incapacitated

 

 

 

 

Other Reasons:

 

 

 

 

 

of Kin

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PART II - EMPLOYER'S CERTIFICATION (for employed members only)

1.PhilHealth Employer No. (PEN):

3. Business Name and Official Address:

2. Contact No.:

(Business Name of Employer)

(Building Number and Street Name)

(City / Municipality)

(Province)

(ZIP Code)

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.

Signature Over Printed Name of Employer / Authorized Representative

Official Capacity / Designation

Date Signed (month-day-year)

(For PhilHealth use only)

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1. The cf1 form download needs particular information to be inserted. Make sure the next blank fields are completed:

The best way to complete cf1 form sample stage 1

2. Once this array of fields is completed, you should add the essential specifics in Reason for Signing on Behalf of, Member is Abroad OutofTown, Member is Incapacitated, Other Reasons, Guardian Next of Kin, PART II EMPLOYERS CERTIFICATION, PhilHealth Employer No PEN, Business Name and Official Address, Contact No, Business Name of Employer, Building Number and Street Name, City Municipality Province ZIP, CERTIFICATION OF EMPLOYER, This is to certify that all, and Signature Over Printed Name of in order to go further.

Filling in segment 2 of cf1 form sample

Always be extremely attentive while filling in PhilHealth Employer No PEN and Contact No, as this is the section where a lot of people make some mistakes.

3. Through this part, look at For PhilHealth use only. All of these have to be taken care of with highest precision.

For PhilHealth use only, For PhilHealth use only, and For PhilHealth use only in cf1 form sample

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