Resources/Forms

Membership

  1. PhilHealth Member Registration Form (PMRF)
  2. PhilHealth Member Registration Form for Foreign Nationals (PMRF-FN)

Claims

  1. Claim Signature Form (Revised September 2018)
  2. Claim Form 1: Member and Patient Information (Revised September 2018)
  3. Claim Form 2: Provider Information (Revised September 2018)
  4. Claim Form 3: Patient’s Clinical Record
  5. Claim Form 4: Clinical Summary
  6. PhilHealth Claim Form 1 Guidelines
  7. PhilHealth Claim Form 2 Guidelines
  8. PhilHealth Claim Form Reminders
  9. PhilHealth Claim Form 4 Guidelines

E-Claims

  1. Software Certification Application Form (SCAF)
  2. Non-Disclosure Agreement (NDA)
  3. Software Certification Agreement (SCA)
  4. eClaims Cloud Storage Technical Specifications
  5. PCSS Application Form

Dialysis Database

  1. Registration Form
  2. Certification on Diagnosis and Management of CKD Stage 5

Payment

  1. PhilHealth Premium Payment Slip (PPPS) for ACAs
  2. PhilHealth Premium Payment Slip (PPPS) for PhilHealth Use Only

Employers

  1. Employer Data Record (ER1)
  2. Report of Employee-Members (ER2)
  3. Employer Data Amendment Form (ER3)
  4. Employer’s Remittance Report (RF1)
  5. PhilHealth Employers’ Engagement Representative (PEER) Information Sheet
  6. Non Disclosure Agreement

Accredited Collecting Agents (ACAs)

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

Kasambahay

  1. Household Employer Unified Registration Form (PPS-HEUR1)
  2. Household Employment Unified Report Form (PPS-HEUR2)
  3. Kasambahay Unified Registration Form (PPS-KUR FORM)
  4. Household PhilHealth Payment Slip (PPS)

COVID-19

  1. Assessment Checklist for COVID-19 Home Isolation Benefit Package
  2. Annex C – SARS-CoV-2 claims summary form and instructions for electronic submission (Cartridge Based PCR)
  3. Annex D – Waiver for Directly Filed Claims for SARS-CoV-2 Testing Package
  4. Annex E – Certificate of classification of at-risk individuals and actual charges for SARS-CoV-2 test
  5. Annex C – SARS-CoV-2 claims summary form and instructions for electronic submission (RT PCR Test)
  6. Annex D – Waiver for Directly Filed Claims for SARS-CoV-2 Testing Package
  7. Annex E – Certificate of classification of at-risk individuals and actual charges for SARS-CoV-2 test

Rheumatic Fever/Rheumatic Heart Disease (RF/RHD)

  1. Pre-authorization checklist (Annex A-RF/RHD)
  2. Member empowerment form (Annex B-ME Form)
  3. Transmittal Form (Annex H)
  4. Checklist of Mandatory Services & Other services (Annex C1 –RF/RHD)
  5. RF/RHD Satisfaction Questionnaire (Annex D-RF/RHD)
  6. Checklist of Requirement for Reimbursement (Annex E-RF/RHD)
  7. Transmittal Form (Annex H)
  8. Checklist of Mandatory Services & Other services (Annex C2 –RF/RHD)
  9. Checklist for Patient Transfer (Annex M-RF/RHD)
  10. [RF/RHD systematic clinical assessment and follow-up form (Annex N-RF/RHD)](https://www.philhealth.gov.ph/downloads/rf-rhd/RF-RHD_AnnexN_OutpatientAssessmentForm_

010319.pdf)

  1. National RF/RHD Registry Data Sheet (Annex O-RF/RHD)
  2. Clinical Pathway (Annex P-RF/RHD)
  3. RF/RHD Passport

Mental Health

  1. Minimum Requirements for Accreditation (Annex A.1)
  2. Patient Mental Health Registry (Annex C)
  3. Transmittal Form (Annex H)
  4. Checklist of Requirements for Reimbursement – Tranche 1 (Annex L.1)
  5. Sample Claim Form 2 – Tranche 1 (Annex I.1)
  6. Checklist of Mandatory Services – Tranche 1 (Annex J.1)
  7. MH Satisfaction Questionnaire (Annex K)
  8. Mental Health Passport (Annex D)
  9. Minimum Requirements for Accreditation (Annex A.2)
  10. Letter of Intent for Patient Transfer (Annex E)
  11. Checklist for Patient Transfer (Annex F)
  12. Patient Referral (Annex G)
  13. Mental Health Benefits Package (Annex B)

Accreditation Documents

  1. e-Claims Implementation Guide

Health Care Professionals

  1. Documentary Requirements for Accreditation of Health Care Professionals (Annex A)
  2. Provider Data Record for Health Care Professionals (Annex B)
  3. Supporting Documents for Updating of Records of Health Care Professionals (Annex C)
  4. Performance Commitment for Health Care Professionals (Annex D)

Health Care Facilities

  1. Documentary Requirement for Accreditation of Health Facilities (Annex A)
  2. Provider Data Record for Health Care Facilities (FILLABLE) (Annex B)
  3. Performance Commitment for Health Facilities (Revised June 2023) (FILLABLE) (Annex C)
  4. Classification of Administrative Offenses of Health Care Providers as Provided in RA No. 10606 (Annex D)
  5. Classification of Offenses of Health Care Providers as Provided in the PROAC of RA No. 11223 (Annex E)
  6. Notice of ACPS compliance for private facilities
  7. Notice of ACPS compliance for public facilities
  8. Notice of ACPS compliance for LGU-owned facilities
  9. Bank Certification
  10. Notice of Change of Bank account for private facilities
  11. Notice of Change of Bank account for public facilities
  12. Notice of Change of Bank account for LGU-owned facilities (p1)
  13. Notice of Change of Bank account for LGU-owned facilities (p2)
  14. Email addresses of the Accreditation and Quality Assurance Section ot the PROs

Z Benefits

  1. Self-Assessment Tools
  2. Acute Lymphocytic Leukemia
  3. Breast Cancer
  4. Tetralogy of Fallot / Ventricular Septal Defect
  5. Kidney Transplant
  6. Coronary Artery Bypass Graft
  7. Prostate Cancer
  8. Cervical Cancer
  9. ZMORPH and Expanded ZMORPH
  10. Selected Orthopedic Implant
  11. Peritoneal Dialysis
  12. [Colon and Rectum Cancer](https://www.philhealth.gov.ph/downloads/accreditation/SAT_ColonRect

umCancer.pdf)

  1. Premature and Small Newborns (rev. 3)
  2. Children with Developmental Disabilities
  3. Children with Disabilities Mobility Impairment
  4. Children with Disabilities Hearing Impairment
  5. Children with Visual Disabilities

Outpatient Benefits for Mental Health

  1. Secondary Prevention of Rheumatic Fever/Rheumatic Heart Disease

Pre-Authorization and Claims Reimbursement

  1. Acute Lymphocytic Leukemia