Membership

PMRF: PhilHealth Member Registration Form

PMRF-FN: PhilHealth Member Registration Form for Foreign Nationals

Claims

Claim Signature Form (Revised September 2018)

Claim Form 1: Member and Patient Information (Revised September 2018)
Claim Form 2: Provider Information (Revised September 2018)
Claim Form 3: Patient's Clinical Record
Claim Form 4: Clinical Summary

PhilHealth Claim Form 1 Guidelines »»
PhilHealth Claim Form 2 Guidelines »»
PhilHealth Claim Form Reminders »»
PhilHealth Claim Form 4 Guidelines »»

E-Claims

Software Certification Application Form (SCAF)
Non-Disclosure Agreement (NDA)
Software Certification Agreement (SCA)

eClaims Cloud Storage Technical Specifications
PCSS Application Form

Dialysis Database

Registration Form
Certification on Diagnosis and Management of CKD Stage 5

Payment

PPPS: PhilHealth Premium Payment Slip (for ACAs)
PPPS: PhilHealth Premium Payment Slip (for PhilHealth Use Only)

Employers

ER1: Employer Data Record
ER2: Report of Employee-Members
ER3: Employer Data Amendment Form
RF1: Employer's Remittance Report

PhilHealth Employers' Engagement Representative (PEER) Information Sheet
Non Disclosure Agreement

Accredited Collecting Agents (ACAs)

Non-Disclosure Agreement (NDA)
PhilHealth Online Access Form (POAF)

Kasambahay

PPS-HEUR1: Household Employer Unified Registration Form
PPS-HEUR2: Household Employment Unified Report Form
PPS-KUR FORM: Kasambahay Unified Registration Form
PPS: Household PhilHealth Payment Slip

COVID-19 Home Isolation Benefit Package

Assessment Checklist for COVID-19 Home Isolation Benefit Package

COVID-19 Testing Package

Cartridge Based PCR
Annex C - SARS-CoV-2 claims summary form and instructions for electronic submission
Annex D - Waiver for Directly Filed Claims for SARS-CoV-2 Testing Package
Annex E - Certificate of classification of at-risk individuals and actual charges for SARS-CoV-2 test

RT PCR Test
Annex C - SARS-CoV-2 claims summary form and instructions for electronic submission
Annex D - Waiver for Directly Filed Claims for SARS-CoV-2 Testing Package
Annex E - Certificate of classification of at-risk individuals and actual charges for SARS-CoV-2 test



Rheumatic Fever/Rheumatic Heart Disease (RF/RHD)

I. Requirements for pre-authorization
A. Pre-authorization checklist (Annex A-RF/RHD)
B. Member empowerment form (Annex B-ME Form)

II. Requirements for submission of claims for reimbursement
A. When claiming for Tranche 1
1. Transmittal Form (Annex H)
2. Checklist of Mandatory Services & Other services (Annex C1 –RF/RHD)
3. RF/RHD Satisfaction Questionnaire (Annex D-RF/RHD)
4. Checklist of Requirement for Reimbursement (Annex E-RF/RHD)
B. When claiming for Tranche 2
1. Transmittal Form (Annex H)
2. Checklist of Mandatory Services & Other services (Annex C2 –RF/RHD)
3. RF/RHD Satisfaction Questionnaire (Annex D-RF/RHD)
4. Checklist of Requirement for Reimbursement (Annex E-RF/RHD)

III. For patients requesting for a transfer to another RF/RHD provider
1. Letter of intent for transfer of RF/RHD care to a referral RF/RHD provider(Annex G-RF/RHD)
2. Checklist for Patient Transfer (Annex M-RF/RHD)

IV. Other forms
1. RF/RHD systematic clinical assessment and follow-up form (Annex N-RF/RHD)
2. National RF/RHD Registry Data Sheet (Annex O-RF/RHD)
3. Clinical Pathway (Annex P-RF/RHD)
4. RF/RHD Passport

Outpatient Benefits For Mental Health

A. General Mental Health Services
1. Accreditation Standards
Minimum Requirements for Accreditation (Annex A.1)
2. Requirement for patient registration
Patient Mental Health Registry (Annex C)
3. When filing claims for reimbursement: Tranche 1
Transmittal Form (Annex H)
Checklist of Requirements for Reimbursement - Tranche 1 (Annex L.1)
Sample Claim Form 2 – Tranche 1 (Annex I.1)
Checklist of Mandatory Services – Tranche 1 (Annex J.1)
MH Satisfaction Questionnaire (Annex K)
Mental Health Passport (Annex D)
4. When filing claims for reimbursement: Tranche 2
Transmittal Form (Annex H)
Checklist of Requirements for Reimbursement - Tranche 2 (Annex L.2)
Sample Claim Form 2 – Tranche 2 (Annex I.2)
Checklist of Mandatory Services – Tranche 2 (Annex J.2)
MH Satisfaction Questionnaire (Annex K)
Mental Health Passport (Annex D)

B. Specialty Mental Health Services
1. Accreditation Standards
Minimum Requirements for Accreditation (Annex A.2)
2. Requirement for patient registration
Patient Mental Health Registry (Annex C)
3. When filing claims for reimbursement: Tranche 1
Transmittal Form (Annex H)
Checklist of Requirements for Reimbursement - Tranche 1 (Annex L.3)
Sample Claim Form 2 – Tranche 1 (Annex I.3)
Checklist of Mandatory Services – Tranche 1 (Annex J.3)
MH Satisfaction Questionnaire (Annex K)
Mental Health Passport (Annex D)
4. When filing claims for reimbursement: Tranche 2
Transmittal Form (Annex H)
Checklist of Requirements for Reimbursement - Tranche 2 (Annex L.4)
Sample Claim Form 2 – Tranche 2 (Annex I.4)
Checklist of Mandatory Services – Tranche 2 (Annex J.4)
MH Satisfaction Questionnaire (Annex K)
Mental Health Passport (Annex D)

C. Requirements for transfer of care
Letter of Intent for Patient Transfer (Annex E)
Checklist for Patient Transfer (Annex F)
Patient Referral (Annex G)

D. Summary of the benefits package
Mental Health Benefits Package (Annex B)