Cf2 Philhealth Form – Fill Out and Use This PDF

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PHILHEALTH

CLAIM FORM 1

Revised May 2000

Note: This form together with Claim Form 2 should be filed with PhilHealth within 60 calendar days from date of discharge.

PART I - MEMBER'S CERTIFICATION (Member to Fill in All Items/Indigent to be Assisted by Hospital Representative)

1. Type of Membership

Employed:

Private Sector

Gov't. Sector

Individually paying:

Others

OWWA

Self-employed

OFW

Indigent

Retiree/Pensioner:

SSS

GSIS

Military

Judiciary

Identification No.

2. Name of Member

3. Date of Birth

Last Name

m m d d

y

y

y y

First Name

4. Civil Status

5. Sex

Single

Separated

Male

Middle Name

Married

Widow/er

Female

6. Address of Member

No., Street

Barangay

Municipality/City

Province

Zip Code

7. Name of Spouse

Last Name

First Name

Middle Name

Not Applicable

8. Name of Patient

Patient is the Member

9. Date of Birth

Last Name

m m d d

y

y

y y

First Name

10. Age

11. Sex

Male

Middle Name

Female

12. Relationship of Patient to Member ( Check applicable box if patient is a dependent )

Legitimate spouse who is not an NHIP Member.

Parent who is 60 years old and above, not an NHIP member/retiree/pensioner and

Unmarried and unemployed, legitimate, legitimated,

wholly dependent on me for support.

acknowledged and illegitimate or legally adopted/step

Unmarried child 21 years old & above with physical/ mental disability, congenital or

child, below 21 years old.

acquired and wholly dependent on me for support.

13.CERTIFICATION of MEMBER: I certify that the foregoing information are true and correct and that the three(3) applicable monthly contributions had been paid within six(6) month prior to the month of this confinement.

Signature of Member

Printed Name & Signature of Witness to Thumbmark

If unable to write, affix Right thumbmark

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

14. Registered Name of Employer

Identification No. of Employer

15. Address of Employer ( No., Street, Barangay/Municipality/City, Province, Zip Code )

No., Street

Barangay

Municipality/City

Province

Zip Code

16.CERTIFICATION of EMPLOYER: This is to certify that three(3) applicable monthly contributions were collected during the six(6) month period prior to the month of this confinement and that the data supplied by the member on Part I are true and conform with our available records.

Signature Over Printed Name of Authorized RepresentativeDate SignedOfficial Capacity

cut here

Member's Copy		This portion should be completely filled up, detached by the hospital and given to member
		ACKNOWLEDGEMENT RECEIPT
Name of Member :			SSS/GSIS/MEC/PhilHealth No. :
Name of Patient :			Confinement Period :
Name of Hospital :			PhilHealth Forms Received by :
Address of Hospital :						Date :

IMPORTANT

1.For currently employed member, the original and properly accomplished Form 1 is sufficient. In case item no. 16 ( Certification of Employer ) is not properly accomplished ( ex. separated from employment, but contribution is still qualified for the confinement period ) submit RF-1 and ME-5 and/or applicable receipts

2.Beneficiary/Hospital representative to attach the following supporting document/s for:

a) Individually paying ( voluntary, self-employed or OFW members), any of the following:

Official Receipts of PhilHealth accredited collecting banks or PhilHealth Bank Receipts (PBR)

Duly validated MI-5 ( Contributions Payment Return Form ) for individually paying members starting January 2000 Official Receipts issued by PhilHealth ( for over the counter payments )

b) SSS/GSIS Retirees, any of the following:

Latest pension voucher

Copy of bank account passbook ( with pages indicating name of pensioner and latest pension entry ) Retirement Certificate issued by the GSIS/SSS

c) AFP/PNP Retirees, any of the following:

General or Special Orders Latest pension voucher

Certification of 120 monthly Medicare/NHIP contributions from the GSIS or from previous employer Service record

d) Retired Judges, any of the following:

Certificate of retirement from the Office of the Court Administration (OCA)

Certification of 120 monthly Medicare/NHIP contributions from the GSIS or from previous employer Service record

e)SSS partial disability pensioners - certificate from SSS indicating coverage/period of pension

f)Dependents of a, b, c, d and e - approved M1b or E1/E4 for SSS members or

SPOUSE - copy of marriage contract CHILD - copy of birth or baptismal certificate

Illegitimate/Legitimated child - birth certificate acknowledged by the father/mother or notarized affidavit of support Legally adopted child - legal adoption paper or notarized affidavit that child is legally adopted

Step-child	.	birth or baptismal certificate with copy of marriage contract or
	.	affidavit by the step-mother or step-father

PARENT - affidavit of support ( original or Certified True Copy )

g) OWWA member/dependent - Certified True Copy of Medicare Eligibility Certificate ( MEC )

Legend:

RF-1	- Quarterly Remittance Report form
ME-5	- Contributions Payment Return form for employed sector
MI-5	- Contributions Payment Return form for individually paying members
M1b	- Membership Data Record form for individually paying
E1	- SSS Membership form for new member
E4	- SSS Member's Data Ammendment form