Philhealth Registration Form PDF Details

In the realm of healthcare registration in the Philippines, the PhilHealth Member Registration Form (PMRF) January 2020 version stands as a crucial document for both new enrollees and existing members seeking to update their information. This form, integral to accessing health insurance benefits under the Universal Health Care (UHC) system, demands careful attention to several key aspects. Individuals are reminded of the importance of their unique and permanent PhilHealth Identification Number (PIN), which must be used in all transactions with PhilHealth. The form caters to a variety of purposes, including registration, updating, and amendment of member details, underscoring the necessity of providing accurate personal information, preferred KonSulTa provider, dependent declarations, and specifying the member type. It is designed to capture comprehensive personal and contact details, from full names and birth details to addresses and contact numbers, ensuring coverage for a wide demographic, including direct contributors like employed individuals, migrant workers, professionals, and indirect contributors such as senior citizens and persons with disability (PWD). Furthermore, the PMRF includes instructions for the declaration of dependents, emphasizing the inclusion of children below 21 years old, the spouse, and parents above 60 years old who are wholly dependent on the member. The form also accommodates individuals with permanent disabilities, reflecting the inclusivity of the PhilHealth program. Through maintaining accurate records and adhering to the form’s guidelines, members can ensure smoother interactions with PhilHealth, facilitating access to essential healthcare services and benefits.

QuestionAnswer
Form NamePhilhealth Registration Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesphilhealth member registration form, philhealth online registration 2020, philhealth gov ph online, pmrf

Form Preview Example

REMINDERS:

1.Your PhilHealth Identification Number (PIN) is your unique and permanent number.

2.Always use your PIN in all transactions with PhilHealth.

3.For Updating/Amendment check the appropriate box and provide details to be accomplished and submit corresponding supporting documents.

4.Please read instructions at the back before filling-out this form.

PMRF

PHILHEALTH MEMBER REGISTRATION FORM

UHC v.1 January 2020

PHILHEALTH IDENTIFICATION NUMBER (PIN)

PURPOSE:

 

REGISTRATION

UPDATING/AMENDMENT

Preferred KonSulTa Provider

I. PERSONAL DETAILS

 

 

NAME

 

NO

 

LAST NAME

FIRST NAME

MIDDLE NAME

MIDDLE

MONONYM

EXTENSION

NAME

 

 

 

(Jr./Sr./III)

 

 

 

 

 

 

(Check if app licable only)

 

 

 

 

MEMBER

MOTHER’s

MAIDEN NAME

SPOUSE

(If Married)

DATE OF BIRTH

 

 

PLACE OF BIRTH (City/Municipality/Province/Country)

PHILSYS ID NUMBER (Optional)

 

 

 

 

(Please indicate country if born outside the Philippines)

m m

d d

y y

y y

 

 

 

SEX

CIVIL STATUS

CITIZENSHIP

 

TAX PAYER IDENTIFICATION NUMBER (TIN) (Optional)

Male

Single

Annulled

FILIPINO

FOREIGN NATIONAL

 

Female

Married

Widow/er

DUAL CITIZEN

 

 

 

 

 

 

 

 

Legally Separated

 

 

 

 

 

 

 

 

 

 

 

 

 

II. ADDRESS and CONTACT DETAILS

PERMANENT HOME ADDRESS

Unit/Room No./Floor Building Name

Lot/Block/Phase/House Number

Street Name

 

 

 

 

 

Subdivision

Barangay

Municipality/City Province/State/Country (If abroad)

ZIP Code

MAILING ADDRESS

SAME AS ABOVE

 

 

Unit/Room No./Floor Building Name Lot/Block/Phase/House Number

Street Name

 

 

 

 

 

Subdivision

Barangay

Municipality/City Province/State/Country (If abroad)

ZIP Code

 

 

 

 

 

Home Phone Number

(COUNTRY CODE + AREA CODE + TELEPHONE NUMBER)

Mobile Number (Required)

Business (Direct Line)

E-mail Address (Required for OFW)

III. DECLARATION OF DEPENDENTS

(Use additional form if necessary)

LAST NAME

FIRST NAME

NAME

EXTENSION (Jr./Sr./III)

MIDDLE NAME

RELATIONSHIP

DATE OF

BIRTH (mm-dd-yyyy)

CITIZENSHIP

NO

MIDDLE MONONYM NAME

(Check if app licable only)

Check if

with

Permanent Disability

IV. MEMBER TYPE

DIRECT CONTRIBUTOR

Employed Private

Kasambahay

Family Driver

Employed Government

Migrant Worker

 

 

Professional Practitioner

Land-Based

Sea-Based

Self-Earning Individual

Lifetime Member

 

 

Individual

Filipinos with Dual Citizenship / Living Abroad

 

 

 

 

Sole Proprietor

Foreign National

 

 

 

 

 

 

Group Enrollment Scheme

PRA SRRV No. _____________________

____________________

ACR I-Card No. _____________________

 

 

 

 

 

 

 

PROFESSION: (Except Employed, Lifetime Members and

MONTHLY INCOME:

PROOF OF INCOME:

Sea-based Migrant Worker)

 

 

 

 

 

 

 

 

 

INDIRECT CONTRIBUTOR

Listahanan

LGU-sponsored

4Ps/MCCT

NGA-sponsored

Senior Citizen

Private-sponsored

PAMANA

Person with Disability

KIA/KIPO

PWD ID No. ______________

Bangsamoro/Normalization

For PhilHealth Use only:

Point of Service (POS) Financially Incapable Financially Incapable

This form may be reproduced and is not for sale

Continue at the back

V. UPDATING/AMENDMENT

Please check:

FROM

TO

Change/Correction of Name

(Last Name, First Name, Name Extension (Jr./Sr./III) Middle Name)

Correction of Date of Birth

Correction of Sex

Change of Civil Status

Updating of Personal Information/Address/

Telephone Number/Mobile Number/e-mail

Address

Under penalty of law, I hereby attest that the information provided, including the documents I have attached to this form, are true and accurate to the best of my knowledge. I agree and authorize PhilHealth for the subsequent validation, verification and for other data sharing purposes only under the following circumstances:

As necessary for the proper execution of processes related to the legitimate and declared purpose;

The use or disclosure is reasonably necessary, required or authorized by or under the law; and,

Adequate security measures are employed to protect my information.

_________________________________________________

_________________

 

Member’s Signature over Printed Name

Date

Please affix right

 

 

 

 

thumbmark if unable to write

FOR PHILHEALTH USE ONLY

RECEIVED BY:

Full Name:

______________________________

PRO/LHIO/Branch:

_____________________________

Date & Time:

______________________________

INSTRUCTIONS

1.All information should be written in UPPER CASE/CAPITAL LETTERS. If the information is not applicable, write “N/A.”

2.All fields are mandatory unless indicated as optional. By affixing your signature, you certify the truthfulness and accuracy of all information provided.

3.A properly accomplished PMRF shall be accompanied by a valid proof of identity for first time registrants, and supporting documents to establish relationship between member and dependent/s for updating or request for amendment.

4.On the PURPOSE, check the appropriate box if for Registration or for Updating/Amendment of information.

5.Indicate preferred KonSulTa provider near the place of work or residence.

6.For PERSONAL DETAILS, all name entries should follow the format given below. Check the appropriate box if registrant has no middle name and/or with single name (mononym).

LAST NAME

FIRST NAME

NAME EXTENSION (JR./SR./III)

MIDDLE NAME

SANTOS

JUAN ANDRES

III

DELA CRUZ

7.Indicate registrant’s/member’s name as it appears in the birth certificate.

8.The full mother’s maiden name of registrant/member must be indicated as it appears in the birth certificate.

9.Indicate the full name of spouse if registrant/member is married.

10.Indicate the complete permanent and mailing addresses and contact numbers.

11.For updating/amendment, check the appropriate box to be updated/amended and indicate the correct data.

12.For MEMBER TYPE, check the appropriate box which best describes your current membership status.

13.For Direct Contributors, except employed, sea-based migrant workers and lifetime members, indicate the profession, monthly income and proof of income to be submitted.

14.For Self-earning individuals, Kasambahays and Family Drivers, indicate the actual monthly income in the space provided.

15.In declaring dependents, provide the full name of the living spouse, children below 21 years old, and parents who are 60 years old and above totally dependent to the member.

16.Dependents with disability shall be registered as principal members in accordance with Republic Act 11228 on mandatory PhilHealth coverage for all persons with disability (PWD).

17.The registrant must affix his/her signature over printed name (or right thumbmark if unable to write) and indicate the date when the PMRF was signed.

How to Edit Philhealth Registration Form Online for Free

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filling in philhealth gov ph stage 1

Type in the data in the Female, Single Married Legally Separated, Annulled Widower, DUAL CITIZEN, II ADDRESS and CONTACT DETAILS, PERMANENT HOME ADDRESS UnitRoom, Hom e Phone Number, Subdivision Baranga y, COUN TRY C OD E AR EA CODE TEL, Mobile Number Required, MAILING ADDRESS UnitRoom NoFloor, SAME AS ABOVE, Bus iness Direct Line, Subdivision Baranga y, and Email Address Required for OFW field.

stage 2 to finishing philhealth gov ph

You should be requested for some relevant information to be able to fill in the DIRECT CONTRIBUTOR, INDIRECT CONTRIBUTOR, Employed Private Employed, Professional Practitioner, Individual Sole Proprietor Group, Kasambahay Family Driver Migrant, SeaBased, Foreign National PRA SRRV No ACR, Listahanan PsMCCT, Senior Citizen, PAMANA KIAKIPO, LGUsponsored NGAsponsored, Person with Disability PWD ID No, BangsamoroNormalization, and For PhilHealth Use only section.

step 3 to completing philhealth gov ph

In the section Please check, FROM, ChangeCorrection of Name Last Name, Correction of Date of Birth, Correction of Sex, Change of Civil Status, Updating of Personal, Under penalty of law I hereby, FOR PHILHEALTH USE ONLY, RECEIVED BY, As necessary for the proper, Full Name, declared purpose, The use or disclosure is, and law and, include the rights and obligations of the parties.

Completing philhealth gov ph stage 4

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