Philhealth Registration Form – Fill Out and Use This PDF

The PhilHealth Registration Form is a crucial document for individuals in the Philippines aiming to enroll or update their membership with the Philippine Health Insurance Corporation (PhilHealth). It records personal details, dependents, type of membership, and allows for updates or amendments to one's information, ensuring eligible members can access healthcare services. Filling out this form accurately is the first step towards securing your health insurance benefits, so click the button below to learn how to complete it and become a PhilHealth member today.

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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.

Question	Answer
Form Name	Philhealth Registration Form
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	philhealth member registration form, philhealth online registration 2020, philhealth gov ph online, pmrf

How to Fill Out PhilHealth Member Registration Form (PMRF)

PhilHealth Member Registration Form (PMRF) at a glance

What it is: PMRF is the PHILHEALTH MEMBER REGISTRATION FORM, UHC v.1 January 2020.

Who signs: 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.

What to bring and attach to PhilHealth Member Registration Form (PMRF)

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.

A filled-in PhilHealth Member Registration Form (PMRF) example: a new employed member registers

PhilHealth Member Registration Form (PMRF) example filled out, example: a new employed member registers — Maria Reyes Sample registers as a new PhilHealth member on the PMRF. She is an employed private member, so MONTHLY INCOME stays empty. She ticks Registration, Female, Single, FILIPINO, Employed Private and SAME AS ABOVE. The picture shows page 1, and its names and figures are sample values. She is registering, so the Updating/Amendment box in Purpose stays empty. She is single, so nothing goes in SPOUSE (If Married) in Personal details. She has a middle name, so the NO MIDDLE NAME and MONONYM boxes in Personal details stay empty. She lists no dependents, so Declaration of dependents stays empty. She signs by hand on paper, so nothing goes in Your signature. The picture shows page 1 only.

How to fill out PhilHealth Member Registration Form (PMRF), box by box

Purpose

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

Preferred KonSulTa provider

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

Personal details

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

For personal details, all name entries should follow this format: last name, first name, name extension (Jr./Sr./III), middle name.

Check the appropriate box if registrant has no middle name and/or with single name (mononym) (Check if applicable only).

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

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

PLACE OF BIRTH (City/Municipality/Province/Country): Please indicate country if born outside the Philippines.

Address and contact details

Indicate the complete permanent and mailing addresses and contact numbers. ADDRESS and CONTACT DETAILS: PERMANENT HOME ADDRESS and MAILING ADDRESS, with Unit/Room No./Floor, Building Name, Lot/Block/Phase/House Number, Street Name, Subdivision, Barangay, Municipality/City, Province/State/Country (If abroad) and ZIP Code.

Home Phone Number, Mobile Number (Required), Business (Direct Line) and E-mail Address (Required for OFW): (COUNTRY CODE + AREA CODE + TELEPHONE NUMBER).

Declaration of dependents

"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."

Last name, first name, middle name, no middle name, name extension (Jr./Sr./III), relationship, mononym (Check if applicable only), citizenship and date of birth (mm-dd-yyyy). Check if with Permanent Disability.

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).

Member type

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

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

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

Updating or amendment

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

Please check: 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, or Updating of Personal Information/Address/Telephone Number/Mobile Number/e-mail Address.

Your signature

By affixing your signature, you certify the truthfulness and accuracy of all information provided.

Under penalty of law, you attest that the information provided, including the documents you have attached to this form, are true and accurate to the best of your knowledge.

More rules for PhilHealth Member Registration Form (PMRF)

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

All fields are mandatory unless indicated as optional.

Your Philhealth Identification Number (PIN) is your unique and permanent number. Always use your PIN in all transactions with Philhealth.

If your situation is different

You are a foreign national

IV. MEMBER TYPE: Foreign National, PRA SRRV No. and ACR I-Card No.

Sources

[1] PhilHealth Member Registration Form (PMRF), UHC v.1 January 2020, Philippine Health Insurance Corporation (the Official source link on this page).