Philhealth Cf1 Form – Fill Out and Use This PDF

PhilHealth Cf1 Form is an official document designed by the Philippine Health Insurance Corporation (PhilHealth) to ensure a stable flow of contributions from its members. Members need to fill out the form accurately in order to be able to access all essential benefits as granted by PhilHealth. This includes entitlement for medical and health care insurance coverage, monitored, efficient payroll accounting system and precautionary measures applicable in terms of dependents. All information indicated on this form should ideally be complete for a smooth processing and fluid availability of services provided.

Philhealth Cf1 Form PDF Details

Processing medical claims can be a tedious and confusing process, but with the right paperwork it doesn't have to be. If you're looking to submit a medical claim in the Philippines, then you'll likely need to fill out a Philhealth CF1 form. This guide will walk you through all of the information that must be provided on the form and provide instructions for how to submit it correctly. With this guide, you'll gain valuable insight into how health claims are processed so that your next one goes as smoothly as possible.

Question	Answer
Form Name	Philhealth Cf1 Form
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	cf1 form download, philhealth cf1 form download, philhealth cf1 forms download, philhealth cf1

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		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	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
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
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:

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

When it comes to Official CapacityDesignation and PRO, be certain you don't make any errors in this current part. Those two could be the most significant fields in this PDF.

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Philhealth Cf1 Form – Fill Out and Use This PDF

Philhealth Cf1 Form PDF Details

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