CF-1 Philhealth Form PDF Details

The Philhealth Form Cf1 is an application for membership in the Philippine health insurance program. This form is used to apply for coverage for you and your dependents. The Philhealth Form Cf1 is available on the Philhealth website, and can be filled out and submitted online. You will need to provide information about yourself and your dependents, including your name, date of birth, and Social Security number. You will also need to provide information about your employment and insurance coverage. If you are applying for coverage as a self-employed individual, you will need to provide information about your business. Once the form is complete, you will need to submit it online or mail it in to the Philhealth office. Coverage through PhilHealth can help you save

QuestionAnswer
Form NameCF-1 Philhealth Form
Form Length1 pages
Fillable?Yes
Fillable fields76
Avg. time to fill out15 min 31 sec
Other namescf1 series of 2018, csf philhealth, how to fill up philhealth form cf1, get cf1

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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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This form will need you to provide specific details; to guarantee accuracy, please be sure to consider the guidelines just below:

1. To begin with, once completing the csf meaning philhealth, beging with the section that contains the next fields:

Part number 1 for submitting get cf1

2. The next stage is usually to fill out these particular blank fields: I hereby certify that the herein, Signature Over Printed Name of, Signature Over Printed Name of, Relationship of the Representative, Date Signed monthdayyear, Date Signed monthdayyear, Reason for Signing on Behalf of, Member is Abroad OutofTown, Member is Incapacitated, Other Reasons, Child, Parent, Spouse, Guardian Next of Kin, and PART II EMPLOYERS CERTIFICATION.

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