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    2018 Claim Signature Form

    Uploaded by

    Lorence Villaceran
    The form collects information about the member, patient, and medical confinement including dates and relationships. It requires certifications from the member, employer if applicable, and consent to access medical records. Signatures are needed from the member, employer, and healthcare professional to process the medical insurance claim.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    2018 Claim Signature Form

    Uploaded by

    Lorence Villaceran
    352 views1 page
    The form collects information about the member, patient, and medical confinement including dates and relationships. It requires certifications from the member, employer if applicable, and consent to access medical records. Signatures are needed from the member, employer, and healthcare professional to process the medical insurance claim.

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    2018ClaimSignatureForm

    Original Title

    2018ClaimSignatureForm

    Copyright

    © © All Rights Reserved

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    The form collects information about the member, patient, and medical confinement including dates and relationships. It requires certifications from the member, employer if applicable, and consent to access medical records. Signatures are needed from the member, employer, and healthcare professional to process the medical insurance claim.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    352 views1 page

    2018 Claim Signature Form

    Uploaded by

    Lorence Villaceran
    The form collects information about the member, patient, and medical confinement including dates and relationships. It requires certifications from the member, employer if applicable, and consent to access medical records. Signatures are needed from the member, employer, and healthcare professional to process the medical insurance claim.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
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    This form may be reproduced and

    Republic of the Philippines is NOT FOR SALE

    CSF
    PHILIPPINE HEALTH INSURANCE CORPORATION
    Citystate Centre 709 Shaw Boulevard, Pasig City
    Call Center (02) 441-7442 l Trunkline (02) 441-7444
    www.philhealth.gov.ph
    email: actioncenter@philhealth.gov.ph
    (Claim Signature Form)
    Revised September 2018
    IMPORTANT REMINDERS: Series #
    PLEASE WRITE IN CAPITAL LETTERS AND CHECK THE APPROPRIATE BOXES.
    All information 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 - MEMBER AND PATIENT INFORMATION AND CERTIFICATION


    1. PhilHealth Identification Number (PIN) of Member: 1 4 0 2 5 0 4 8 6 5 9 2
    2. Name of Member: 3. Member Date of Birth:
    VILLACAERAN
    _____________________________ LORENCE
    _____________________________ _____________________________ GALLO
    ________________________ 0 9 0 2 1 9 8 3
    Last Name First Name Name Extension Middle Name month day year
    (JR/SR/III) (ex: DELA CRUZ JUAN JR SIPAG)

    4. PhilHealth Identification Number (PIN) of Dependent:


    5. Name of Patient: 6. Relationship to Member:
    _____________________________ _____________________________ _____________________________ ________________________ child parent spouse
    Last Name First Name Name Extension Middle Name
    (JR/SR/III) (ex: DELA CRUZ JUAN JR SIPAG)

    7. Confinement Period: 8. Patient Date of Birth:


    a. Date Admitted: b. Date Discharged:
    month day year month day year month day year
    9. CERTIFICATION OF MEMBER:
    Under the penalty of law, I attest that the information I provided in this Form are true and accurate to the best of my knowledge.
    LORENCE G. VILLACERAN
    ________________________________________ ____________________________________________________
    Signature Over Printed Name of Member Signature Over Printed Name of Member’s Representative
    Date Signed Date Signed
    month day year month day year
    If member/representative is unable to write, Relationship of the Spouse Child Parent
    put right thumbmark. Member/Representative representative to the member Sibling Others, Specify ___________________
    should be assisted by an HCI representative.
    Check the appropriate box.
    Reason for signing on Member is incapacitated
    Member Representative
    behalf of the member Other reasons: _______________________________

    PART II - EMPLOYER’S CERTIFICATION (for employed members only)

    1. PhilHealth Employer Number (PEN): 0 1 4 0 0 0 0 0 2 2 8 5 2. Contact No.: ______________________________________


    3. Business Name: DEPARTMENT OF EDUCATION - ZAMBOANGA CITY - SECONDARY EDUCATION - TICTAPUL NATIONAL HIGH SCHOOL
    _______________________________________________________________________________________________________________________________________
    Business Name of Employer

    4. CERTIFICATION OF EMPLOYER:
    “This is to certify that the required 3/6 monthly premium contributions plus at least 6 months contributions preceding the 3 months qualifying contributions within 12
    month period prior to the first day of confinement (sufficient regularity) have been regularly remitted to PhilHealth. Moreover, the information supplied by the member or
    his/her representative on Part I are consistent with our available records.”
    EVELYN I. CIELO, Ed. D.
    _____________________________________________________________________ SCHOOL HEAD
    _________________________________________ Date Signed
    Signature Over Printed Name of Employer/Authorized Representative Official Capacity/Designation month day year

    PART III - 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 legal liabilities relative to the herein-mentioned consent which I have
    voluntarily and willingly given in connection with this claim for reimbursement before PhilHealth.
    LORENCE G. VILLACERAN
    _________________________________________________________________________ Date Signed
    Signature Over Printed Name of Member/Patient/Authorized Representative month day year
    If member/representative is unable to write, Relationship of the Spouse Child Parent
    put right thumbmark. Member/Representative representative to the patient Sibling Others, Specify ___________________
    should be assisted by an HCI representative.
    Check the appropriate box.
    Reason for signing on Patient is incapacitated
    Patient Representative
    behalf of the patient Other reasons: _______________________________

    PART IV - HEALTH CARE PROFESSIONAL INFORMATION


    Accreditation No. _____________________________________________ Date Signed
    Signature Over Printed Name month day year
    Accreditation No. _____________________________________________ Date Signed
    Signature Over Printed Name month day year
    Accreditation No. _____________________________________________ Date Signed
    Signature Over Printed Name month day year

    PART V - PROVIDER INFORMATION AND CERTIFICATION


    1. PhilHealth Benefits: ICD 10 or RVS Code: 1. First Case Rate ______________________________ 2. Second Case Rate ____________________________________
    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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