Philhealth Cf1 Form PDF Details

The PhilHealth Claim Form 1, also known as CF-1, serves as a critical document for members of the Philippine Health Insurance Corporation seeking to avail themselves of health insurance benefits. This form, which may be freely reproduced but is not for sale, is a testament to the Republic of the Philippines' commitment to providing accessible healthcare information and services. The CF-1 form, revised in September 2018, contains important reminders for filers, emphasizing the need for legibility, accuracy, and completeness in providing information. It outlines the specific windows—60 days for local claims and 180 days for claims abroad—within which members must file their claims following discharge. The form seeks detailed member information, including the PhilHealth Identification Number (PIN), name, date of birth, contact details, and mailing address. Furthermore, for patients who are dependents of the member, it gathers pertinent data about the patient's relationship to the member and their own identification details. PhilHealth underscores the form's role in ensuring accountability and preventing fraud through a certification section, where members attest to the truthfulness and accuracy of the information provided. This process is supported by healthcare institution representatives and, for employed members, includes an employer’s certification verifying the member's contribution history. With such comprehensive requirements, the CF-1 form plays an essential role in the efficient and transparent administration of health insurance claims in the Philippines.

QuestionAnswer
Form NamePhilhealth Cf1 Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namescf1 form download, philhealth cf1 form download, philhealth cf1 forms download, philhealth cf1

Form Preview Example

 

This form may be reproduced and

 

is NOT FOR SALE

Republic of the Philippines

CF-1

PHILIPPINE HEALTH INSURANCE CORPORATION

Citystate Centre 709 Shaw Boulevard, Pasig City

Call Center (02) 441-7442 • Trunkline (02) 441-7444

(Claim Form 1)

www.philhealth.gov.ph

Revised September 2018

email: actioncenter@philhealth.gov.ph

 

Series #

IMPORTANT REMINDERS:

PLEASE WRITE IN CAPITAL LETTERS AND CHECK THE APPROPRIATE BOXES.

For local availment, this form together with other PhilHealth claim forms and other supporting documents should be filed within 60 days from date of discharge. For availment of benefits abroad, this form together with other supporting documents should be filed within 180 days from date of discharge.

Representative of the Health Care Institutions (HCI) shall assist the member/authorized representative in filling out this form. All information required in this form are necessary. 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 INFORMATION

1.PhilHealth Identification Number (PIN) of Member:

2.Name of Member:

3.Date of Birth:

_____________________________

_____________________________ _____________________________ ________________________

 

 

 

 

 

 

 

 

 

 

Last Name

First Name

Name Extension

Middle Name

month

 

day

 

 

(JR/SR/III)

(ex: DELA CRUZ JUAN JR SIPAG)

 

 

 

4.Mailing Address:

 

 

 

5.Sex:

 

Male

 

 

 

 

year

Female

_____________________________

_____________________________

_____________________________

________________________

________________________________________

Unit/Room No./Floor

Building Name

Lot/Blk/House/Bldg.No

Street

Subdivision/Village

_____________________________

_____________________________

_____________________________

________________________

________________________________________

Barangay

City/Municipality

Province

Country

Zip Code

6.Contact Information:

_______________________________________________________ _______________________________________________

________________________________________________________

Landline No. (Area Code + Tel. No.)

 

Mobile No.

Email Address

7.Patient is the member?

 

Yes, Proceed to Part III

 

No, Proceed to Part II

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PART II - PATIENT INFORMATION (To be filled-out only if the patient is a dependent)

1.PhilHealth Identification Number (PIN) of Dependent:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.Name of Patient:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.Date of Birth:

_____________________________ _____________________________

_____________________________

________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last Name

 

First Name

Name Extension

 

Middle Name

 

 

 

 

 

 

 

 

 

 

month

 

day

 

 

 

 

 

 

 

(JR/SR/III)

(ex: DELA CRUZ JUAN JR SIPAG)

 

 

 

 

 

 

 

4.Relationship to Member:

 

Child

 

Parent

 

Spouse

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.Sex:

 

 

Male

year

Female

PART III - MEMBER CERTIFICATION

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.

________________________________________

Signature Over Printed Name of Member

Date Signed

 

month day

year

If member/representative is unable to write, put right thumbmark. Member/Representative should be assisted by an HCI representative. Check the appropriate box.

Member

 

Representative

____________________________________________________

Signature Over Printed Name of Member’s Representative

Date Signed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

month

day

year

 

 

 

 

 

 

 

 

 

Relationship of the

 

 

Spouse

 

Child

 

Parent

 

 

 

 

 

 

 

representative to the member

 

 

Sibling

 

Others, Specify ___________________

 

 

 

 

 

 

 

 

 

Reason for signing on

 

 

 

Member is incapacitated

 

 

 

 

 

 

 

 

behalf of the member

 

 

Other reasons: _______________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PART IV - EMPLOYER’S CERTIFICATION (for employed members only)

1.PhilHealth Employer Number (PEN):

3.Business Name:

2.Contact No.: ______________________________________

__________________________________________________________________________________________________________________________________________

Business Name of Employer

4.CERTIFICATION OF EMPLOYER:

“This is to certify that the required 3/6 monthly premium contributions plus at least 6 months contributions preceding the 3 months qualifying contributions within 12 month period prior to the first day of confinement (sufficient regularity) have been regularly remitted to PhilHealth. Moreover, the information supplied by the member or his/her representative on Part I are consistent with our available records.”

_____________________________________________

_______________________________

Date Signed

 

 

 

 

 

 

 

 

 

 

Signature Over Printed Name of Employer/Authorized Representative

Official Capacity/Designation

 

month day

year

PART V - FOR PHILHEALTH USE ONLY

Date Received: LHIO PRO

By:

LHIO/PRO Signature Over Printed Name

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This PDF requires particular details to be entered, so be sure you take the time to enter what is expected:

1. The philhealth claim form needs specific information to be entered. Make certain the following blank fields are filled out:

Part # 1 in submitting cf1 form 2021

2. Once your current task is complete, take the next step – fill out all of these fields - PART II PATIENT INFORMATION To be, PhilHealth Identification Number, Name of Patient, Date of Birth, Last Name, First Name, Name Extension, JRSRIII, Middle Name, ex DELA CRUZ JUAN JR SIPAG, month day year, Relationship to Member Child, Sex Male Female, PART III MEMBER CERTIFICATION, and Under the penalty of law I attest with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Find out how to prepare cf1 form 2021 part 2

3. This third stage is hassle-free - fill out all of the blanks in month period prior to the first, Signature Over Printed Name of, Date Signed, Official CapacityDesignation, month day year, PART V FOR PHILHEALTH USE ONLY, Date Received, LHIO, PRO, and LHIOPRO Signature Over Printed Name to conclude this part.

Official CapacityDesignation, PRO, and Signature Over Printed Name of of cf1 form 2021

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