Philhealth CF-2 Form PDF Details

In the realm of social health insurance in the Philippines, the PhilHealth CF2 form stands as a crucial document for processing medical claims and ensuring that beneficiaries receive the appropriate healthcare coverage. This form, officially a release by the Philippine Health Insurance Corporation, is part of a streamlined process designed to provide clarity and ease in settling medical claims. As indicated on the document, it may be reproduced and is explicitly not for sale, emphasizing its accessibility and utility for all Filipinos covered under the PhilHealth program. The form, last revised in September 2018, requires submission within a strict timeframe of sixty calendar days following the patient's date of discharge, underscoring the importance of timely filing. It encompasses detailed sections, including health care institution information, patient confinement details, diagnoses, and a certification of the consumption of benefits, each meticulously designed to capture comprehensive data pertinent to the claim. Instructions stress the importance of writing in capital letters and checking the appropriate boxes, with an admonition that incomplete information will lead to processing delays. Moreover, the form includes strict reminders against false or incorrect information which could result in criminal, civil, or administrative liabilities, thus upholding the integrity of the submission process. Importantly, it accommodates details not only on the diagnosis and treatment received but also supports the inclusion of special considerations such as the Z-Benefit Package and procedures like chemotherapy or hemodialysis, further illustrating the form's adaptability to various patient needs.

QuestionAnswer
Form NamePhilhealth CF-2 Form
Form Length2 pages
Fillable?Yes
Fillable fields222
Avg. time to fill out22 min 29 sec
Other namesphilhealth claim form 2, philhealth form cf2, cf2 form, csf2 form

Form Preview Example

 

This form may be reproduced and

 

is NOT FOR SALE

Republic of the Philippines

CF-2

PHILIPPINE HEALTH INSURANCE CORPORATION

Citystate Centre 709 Shaw Boulevard, Pasig City

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

(Claim Form 2)

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.

This form together with other supporting documents should be filed within sixty (60) calendar days from date of discharge.

All information, fields and trick boxes 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 - HEALTH CARE INSTITUTION (HCI) INFORMATION

1.PhilHealth Accreditation Number (PAN) of Health Care Institution:

2.Name of Health Care Institution: _________________________________________________________________________________________________________________________

3.Address: ____________________________________________________________ __________________________________________ ________________________________________

Building Number and Street NameCity/MunicipalityProvince

PART II - PATIENT CONFINEMENT INFORMATION

1.Name of Patient:

________________________________

___________________________________

________________________

___________________________________

 

Last Name

First Name

Name Extension

Middle Name

 

 

 

(JR/SR/III)

(ex: DELA CRUZ JUAN JR SIPAG)

2.Was patient referred by another Health Care Institution (HCI)?

 

 

NO

 

YES ___________________________________________

_________________________________

 

 

 

 

 

Name of referring Health Care Institution

 

 

Building Number and Street Name

3.Confinement Period:

a. Date Admitted

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b. Time Admitted

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

month

day

 

 

year

 

 

 

 

 

c. Date Discharge

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

d. Time Discharge

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

month

day

 

 

year

4.Patient Disposition: (select only 1)

___________________

_____________________ ___________

City/Municipality

 

 

Province

Zip code

 

 

:

 

 

 

 

 

 

 

 

AM

 

PM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

hour

:

 

min

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AM

 

PM

 

 

 

 

 

 

 

 

hour

 

 

min

 

 

 

 

 

 

 

 

 

 

 

 

a. Improved

 

 

 

 

 

e. Expired

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Time:

 

 

 

 

 

:

 

 

 

 

 

 

 

 

AM

 

 

PM

 

 

 

 

 

 

 

 

 

 

month

 

day

 

year

 

 

hour

 

 

min

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b. Recovered

 

 

 

 

 

f. Transferred/Referred

___________________________________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Referral Health Care Institution

 

 

 

c. Home/Discharged Against Medical Advise

_____________________________

________________

 

 

__________________

_________

 

 

d. Absconded

 

 

 

 

 

 

 

 

 

Building Number and Street Name

City/Municipality

 

 

 

Province

Zip code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Reason/s for referral/transfer: ____________________________________________________________________

5.Type of Accomodation:

 

 

 

 

 

 

Private

 

 

Non-Private (Charity/Service)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6.Admission Diagnosis/es:

7.Discharge Diagnosis/es (Use additional CF2 if necessary):

Diagnosis

ICD-10 Code/s

Related Procedure/s (if there’s any)

RVS Code

Date of Procedure

a. __________________

______________

i. _____________________________

_______________

________________

__________________

______________

ii. _____________________________

_______________

________________

__________________

______________

iii. _____________________________

_______________

________________

b. __________________

______________

i. _____________________________

_______________

________________

__________________

______________

ii. _____________________________

_______________

________________

__________________

______________

iii. _____________________________

_______________

________________

Laterality (check applicable box)

left

 

right

 

both

left

 

right

 

both

 

 

left

 

right

 

both

left

 

right

 

both

 

 

left

 

right

 

both

left

 

right

 

both

8.Special Considerations:

a. For the following repetitive procedures, check box that applies and enumerate the procedure/sessions dates [mm-dd-yyyy]. For chemotherapy, see guidelines.

Hemodialysis

______________________________________

 

Blood Transfusion

______________________________________

Peritoneal Dialysis

______________________________________

 

Brachytherapy

______________________________________

 

Radiotherapy (LINAC)

______________________________________

 

Chemotherapy

______________________________________

 

Radiotherapy (COBALT)

______________________________________

 

Simple Debridement

______________________________________

 

b. For Z-Benefit Package

Z-Benefit Package Code: _________________________________________

c. For MCP Package (enumerate four dates [mm-dd-year] of pre-natal check-ups)

1 _________________________________ 2 ______________________________ 3 ___________________________ 4 _________________________________

d. For TB DOTS Package

 

 

Intensive Phase

 

 

Maintenance Phase

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

e. For Animal Bite Package (write the dates [mm-dd-year] when the following doses of vaccine were given)

Note: Anti Rabies Vaccine (ARV), Rabies Immunoglobulin (RIG)

 

 

 

 

 

 

 

 

 

 

 

 

 

Day 0 ARV _______________

 

Day 3 ARV __________________ Day 7 ARV ______________

RIG _________________

Others (Specify) _______________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

f. For Newborn Care Package

 

 

Essential Newborn Care

 

Newborn Hearing Screening Test

 

Newborn Screening Test

 

For Newborn Screening,

 

 

 

 

 

 

 

 

 

 

 

 

 

please attach NBS Filter Sitcker here

For Essential Newborn Care (check applicable boxes)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Immediate drying of newborn

Early skin-to-skin contact

Timely cord clamping

Eye Prophylaxis

Weighing of the newborn

Vitamin K administration

BCG vaccination

 

Hepatitis B vaccination

 

 

 

Non-separation of mother/baby for early breastfeeding initiation

g. For Outpatient HIV/AIDS Treatment Package

Laboratory Number: ____________________________________

9.PhilHealth Benefits:

ICD 10 or RVS Code:

a. First Case Rate ____________________________________________ 2. Second Case Rate __________________________________________

10.Accreditation Number/Name of Accredited Health Care Professional/Date Signed and Professional Fees/Charges

(Use additional CF2 if necessary):

Accreditation number/Name of Accredited Health Care Professional/Date Signed

 

 

Details

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Accreditation No.:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

____________________________________________________________

 

 

No co-pay on top of PhilHealth Benefit

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature Over Printed Name

 

 

With co-pay on top of PhilHealth Benefit

P

______________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date Signed:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

month

 

day

 

 

year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Accreditation No.:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

____________________________________________________________

 

 

No co-pay on top of PhilHealth Benefit

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature Over Printed Name

 

 

With co-pay on top of PhilHealth Benefit

P

______________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date Signed:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

month

 

day

 

 

year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Accreditation No.:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

____________________________________________________________

 

 

No co-pay on top of PhilHealth Benefit

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature Over Printed Name

 

 

With co-pay on top of PhilHealth Benefit

P

______________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date Signed:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

month

 

day

 

 

year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PART III - CERTIFICATION OF CONSUMPTION OF BENEFITS AND CONSENT TO ACCESS PATIENT RECORD/S

NOTE: Member/Patient should sign only after the applicable charges have been filled-out

A.CERTIFICATION OF CONSUMPTION OF BENEFITS:

PhilHealth benefit is enough to cover HCI and PF Charges.

No purchase of drugs/medicines, supplies, diagnostics, and co-pay for professional fees by the member/patient.

Total Health Care Institution Fees

Total Professional Fees

Grand Total

Total Actual Charges*

The benefit of the member/patient was completely consumed prior to co-pay OR the benefit of the member/patient is not completely consumed BUT with purchases/expenses for drugs/medicines, supplies, diagnostics and others.

a.) The total co-pay for the following are:

 

 

Amount after Application

 

 

 

 

 

 

 

Total Actual Charges*

of Discount (i.e., personal

 

PhilHealth Benefit

Amount after PhilHealth Deduction

 

 

discount, Senior Citizen/PWD)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Amount P _______________________

Total Health Care

 

 

 

 

 

Paid by (check all that applies):

Institution Fees

 

 

 

 

 

Member/Patient

HMO

 

 

 

 

 

 

Others (i.e., PCSO, Promisory note, etc.)

 

 

 

 

 

 

 

Total Professional

 

 

 

 

 

Amount P _______________________

Fees (for accredited

 

 

 

 

 

Paid by (check all that applies):

and non-accredited

 

 

 

 

 

Member/Patient

HMO

professionals)

 

 

 

 

 

Others (i.e., PCSO, Promisory note, etc.)

 

 

 

 

 

 

 

 

 

b.) Purchases/Expenses NOT included in the Health Care Institution Charges

 

 

 

 

 

 

 

 

 

 

 

Total cost of purchase/s for drugs/medicines and/or medical supplies bought by the

 

None

Total Amount

P

_______________

patient/member within/outside the HCI during confinement

 

 

 

 

 

 

 

 

 

 

 

 

Total cost of diagnostic/laboratory examinations paid by the patient/member done

 

None

Total Amount

P

_______________

within/outside the HCI during confinement

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*NOTE: Total Actual Charges should be based on Statement of Account (SOA)

B.CONSENT TO ACCESS PATIENT RECORD/S:

I hereby consent to the submission and examination of the patient’s pertinent medical records for the purpose of verifying the veracity of this claim to effect efficient processing of benefit payment.

I hereby hold PhilHealth or any of its officers, employees and/or representatives free from any and all legal liabilities relative to the herein-mentioned consent which I have voluntarily and willingly given in connection with this claim for reimbursement before PhilHealth.

_____________________________________________________________

Signature Over Printed Name of Member/Patient/Authorized Representative

Date Signed:

month

day

year

 

Relationship of the representative to

Spouse

Child

Parent

the member/patient:

Sibling

Others, Specify ___________________

Reason for signing on behalf of the

Patient is Incapacitated

 

member/patient:

Other Reasons _______________________________

If patient/representative is unable to write, put right thumbmark. Patient/ Representative should be assisted by an HCI representative.

Patient

Representative

PART IV - CERTIFICATION OF CONSUMPTION OF HEALTH CARE INSTITUTION

I certify that services rendered were recorded in the patient’s chart and health care institution records and that the herein information given are true and correct.

____________________________________________________

__________________________________________

Date Signed:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature Over Printed Name of Authorized HCI Representative

Official Capacity/Designation

 

 

month

day

year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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