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Downloads

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

  • Account & Cipher Key Request Form
  • HCI Engagement Registration Form

    • Maternity Care Benefits
  • Annex C: Antenatal Care Record
  • Annex E: Post Partum Care Record
    • Dialysis Database
  • Registration Form
  • Certification on Diagnosis and Management of CKD Stage 5
  • Hemodialysis Benefits Package Agreement Form

    • 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


    • Health IT Partners
  • e-Claims Implementation Guide »

    • Health Care Professionals
  • Annex A:Documentary Requirements for Accreditation of Health Care Professionals
  • Annex B: Provider Data Record for Health Care Professionals
  • Annex C: Supporting Documents for Updating of Records of Health Care Professionals
  • Annex D: Performance Commitment for Health Care Professionals

    • Health Care Facilities
  • Annex A: Documentary Requirement for Accreditation of Health Facilities
  • Annex B: Provider Data Record for Health Care Facilities (FILLABLE)
  • Annex C: Performance Commitment for Health Facilities (Revised June 2023) (FILLABLE)
  • Annex D: Classification of Administrative Offenses of Health Care Providers as Provided in RA No. 10606
  • Annex E: Classification of Offenses of Health Care Providers as Provided in the PROAC of RA No. 11223

  • PC 2026-0002: Performance Commitment for PhilHealth GAMOT Facility (FILLABLE)

  • ACPS Forms
  • A. Notice of ACPS compliance for private facilities
  • B. Notice of ACPS compliance for public facilities
  • C. Notice of ACPS compliance for LGU-owned facilities
  • D. Bank Certification
  • E. Notice of Change of Bank account for private facilities
  • F. Notice of Change of Bank account for public facilities
  • G. Notice of Change of Bank account for LGU-owned facilities (p1)
  • G. Notice of Change of Bank account for LGU-owned facilities (p2)

  • Email addresses of the Accreditation and Quality Assurance Section ot the PROs

    • Self-Assessment Tools
  • Acute Lymphocytic Leukemia
  • Breast Cancer
  • Kidney Transplant
  • Prostate Cancer
  • Cervical Cancer
  • ZMORPH and Expanded ZMORPH
  • Selected Orthopedic Implant
  • Peritoneal Dialysis
  • Colon and Rectum Cancer
  • Premature and Small Newborns (rev. 3)
  • Children with Developmental Disabilities
  • Children with Disabilities Mobility Impairment
  • Children with Disabilities Hearing Impairment
  • Children with Visual Disabilities
  • Heart Valve Repair and/or Replacement for Valvular Heart Disease
  • Open Heart Surgeries (CABG & VHD*)
  • Open Heart Surgeries (VSD/TOF/VHD*)
  • Post-Kidney Transplantation Services in Adults
  • Post-Kidney Transplantation Services in Children
  • Heart Valve Repair and/or Replacement for Valvular Heart Disease

    • Pre-Authorization and Claims Reimbursement


    Acute Lymphocytic Leukemia
  • I. Requirements for Pre-authorization
  • A. Pre-authorization Checklist and Request (Annex A)
  • B. Member Empowerment Form (Annex B)

  • II. Requirement for submission of claims for reimbursement

    • A. When claiming for reimbursement: Tranche 1

  • Transmittal Form (Annex H)
  • Tranche Requirements Checklist (Annex E1)
  • Checklist of Mandatory Services and other services (Annex C1)
  • Z Satisfaction Questionnaire (Annex D)

    • B. When claiming for reimbursement: Tranche 2

  • Transmittal Form (Annex H)
  • Tranche Requirements Checklist (Annex E2)
  • Checklist of Mandatory Services and other services (Annex C2)
  • Z Satisfaction Questionnaire (Annex D)

    • C. When claiming for reimbursement: Tranche 3

  • Transmittal Form (Annex H)
  • Tranche Requirements Checklist (Annex E3)
  • Checklist of Mandatory Services and other services (Annex C3)
  • Z Satisfaction Questionnaire (Annex D)
    • Breast Cancer
  • I. Requirements when filing claims for Diagnostic Tests and Prognostication of Breast Cancer
  • Annex H: Transmittal Form
  • Annex A.1: Checklist of Eligibility Criteria for Diagnostic Tests and Prognostication – Breast Cancer
  • Annex C.1. Checklist of Mandatory and Other Services for Diagnostics and Prognostication
  • Annex D: Z Satisfaction Questionnaire
  • Annex E.1. Checklist of Requirements for Reimbursement – Diagnostic Tests and Prognostication

  • II. Requirements for Pre-authorization
  • Annex A.2: Pre-authorization Checklist and Request Form
  • Annex B: Member Empowerment (ME) Form

  • III. Requirements for submission of claims for reimbursement

    • A. When filing claims for surgical procedure of breast cancer

  • Annex H: Transmittal Form
  • Annex C.2. Checklist of Mandatory and Other Services for Surgery
  • Annex D: Z Satisfaction Questionnaire
  • Z Satisfaction Questionnaire (Annex D)

    • C. When filing claims for chemotherapy of breast cancer

  • Transmittal Form (Annex H)
  • Annex C.3. Checklist of Mandatory and Other Services for Chemotherapy
  • Annex D: Z Satisfaction Questionnaire
  • Annex E.3. Checklist of Requirements for Reimbursement – Chemotherapy
  • Annex F: Breast Cancer Treatment Passport

    • D. Hormonotherapy
    D.1. When filing claims for Hormonotherapy: Tranche 1

  • Transmittal Form (Annex H)
  • Annex C.4.1. Checklist of Mandatory and Other Services for Hormonotherapy Tranche 1
  • Annex D: Z Satisfaction Questionnaire
  • Annex E.4.1. Checklist of Requirements for Reimbursement – Hormonotherapy Tranche 1
  • Annex F: Breast Cancer Treatment Passport

    • D.2. When filing claims for Hormonotherapy: Tranche 2

  • Transmittal Form (Annex H)
  • Annex C.4.2.Checklist of Mandatory and Other Services for Hormonotherapy Tranche 2
  • Annex D: Z Satisfaction Questionnaire
  • Annex E.4.2.Checklist of Requirements for Reimbursement – Hormonotherapy Tranche 2
  • Annex F: Breast Cancer Treatment Passport

    • E. Targeted Therapy
    E.1. When filing claims for Targeted Therapy: Tranche 1

  • Transmittal Form (Annex H)
  • Annex C.5.1. Checklist of Mandatory and Other Services for Targeted Therapy - Tranche 1
  • Annex D: Z Satisfaction Questionnaire
  • Annex E.5.1. Checklist of Requirements for Reimbursement – Targeted Therapy Tranche 1
  • Annex F: Breast Cancer Treatment Passport

    • E.2. When filing claims for Targeted Therapy: Tranche 2

  • Transmittal Form (Annex H)
  • Annex C.5.2. Checklist of Mandatory and Other Services for Targeted Therapy - Tranche 2
  • Annex D: Z Satisfaction Questionnaire
  • Annex E.5.2.Checklist of Requirements for Reimbursement – Targeted Therapy Tranche 2
  • Annex F: Breast Cancer Treatment Passport

    • E.3. When filing claims for Targeted Therapy: Tranche 3

  • Transmittal Form (Annex H)
  • Annex C.5.3. Checklist of Mandatory and Other Services for Targeted Therapy - Tranche 3
  • Annex D: Z Satisfaction Questionnaire
  • Annex E.5.3. Checklist of Requirements for Reimbursement – Targeted Therapy Tranche 3
  • Annex F: Breast Cancer Treatment Passport

    • F. When filing claims for surveillance of breast cancer

  • Transmittal Form (Annex H)
  • Annex C.6. Checklist of Mandatory and Other Services for Surveillance
  • Annex D: Z Satisfaction Questionnaire
  • Annex E.6. Checklist of Requirements for Reimbursement – Surveillance

    • G. Patient transfer

  • Annex G: Checklist for Patient Transfer
  • Annex I: Letter of Intent for Transfer to a Contracted Health Facility

    • H. Sample Claim Form (CF) 2

  • Annex J.1. Diagnostic Tests or Prognostication
  • Annex J.2. Surgery
  • Annex J.3. Cytotoxic Chemotherapy
  • Annex J.4.1. Hormonotherapy Tranche 1
  • Annex J.4.2. Hormonotherapy Tranche 2
  • Annex J.5.1. Targeted Therapy Tranche 1
  • Annex J.5.2. Targeted Therapy Tranche 2
  • Annex J.5.3. Targeted Therapy Tranche 3
  • Annex J.6. Surveillance

    • I. Other Documents

  • Annex K: Pathway of the Benefits Availment of Z Benefits for Breast Cancer
  • Annex L: Breast Cancer Treatment Protocols
  • Annex M: Breast Cancer Medical Records Summary Form
  • Annex N: Outcome Indicators
  • Annex O: Guide on Co-payment Proposal of the Z Benefits Package for Breast Cancer
    • Cervical Cancer
  • I. Prior to availment of benefits
  • Pre-authorization Checklist and Request Form (Annex A)
  • Member Empowerment Form (Annex B)

  • II. When filing claims for the surgery for cervical cancer stage IA1, IA2-IIA1
  • Transmittal Form (Annex H)
  • Checklist of Requirements for Reimbursement (Annex E1.1 – Cervical CA)
  • Checklist of mandatory and other services (Annex C1.1 – Cervical CA)
  • Z Satisfaction Questionnaire (Annex D)

  • III. When filing claims for chemoradiation with cobalt and brachytherapy (low dose) for cervical cancer
  • Transmittal Form (Annex H)
  • Checklist of Requirements for Reimbursement (Annex E1.2 – Cervical CA)
  • Checklist of mandatory and other services (Annex C1.2 – Cervical CA)
  • Z Satisfaction Questionnaire (Annex D)

  • IV. When filing claims for chemoradiation with linear accelerator and brachytherapy (low/high dose) for cervical cancer
  • Transmittal Form (Annex H)
  • Checklist of Requirements for Reimbursement (Annex E1.3 – Cervical CA)
  • Checklist of mandatory and other services (Annex C1.3 – Cervical CA)
  • Z Satisfaction Questionnaire (Annex D)
    • Colon Cancer
  • STAGE I-II (LOW RISK)
  • 1. Prior to availment of the Benefits
  • Annex A1: Pre-authorization Checklist and Request for Colon Cancer
  • Annex B: Member Empowerment Form

  • 2. Requirements for submission of claims for reimbursement (Post-surgery)
  • Annex H: Transmittal Form of Claims for the Z Benefits
  • Annex E1.1: Checklist of tranche requirements (Tranche 1)
  • Annex C1.1: Checklist of mandatory and other services
  • Annex D: Z Satisfaction Questionnaire

  • STAGE II (HIGH RISK)
  • 1. Prior to availment of the Benefits
  • Annex A1: Pre-authorization Checklist and Request for Colon Cancer
  • Annex B: Member Empowerment Form

  • 2. Requirements for submission of claims for reimbursement (Post-surgery)
  • Annex H: Transmittal Form of Claims for the Z Benefits
  • Annex E1.2: Checklist of tranche requirements (Tranche 1)
  • Annex C1.2: Checklist of mandatory and other services
  • Annex D: Z Satisfaction Questionnaire

  • 3. Requirements for submission of claims for reimbursement (After last cycle of chemotherapy)
  • Annex H: Transmittal Form of Claims for the Z Benefits
  • Annex E1.3: Checklist of tranche requirements (Tranche 2)
  • Annex C1.3. Checklist of mandatory and other services
  • Annex D: Z Satisfaction Questionnaire

  • Other Annexes
  • Annex F: Quality Indicators for the Z Benefits for Colorectal Cancers
  • Annex G: Pathway for the Z Benefits for Colon and Rectal Cancers
  • Annex I: Outcomes Report Form for Colon and Rectal Cancers

    • Rectal Cancer
  • STAGE I (CLINICAL AND PATHOLOGIC)
  • 1. Prior to availment of the Benefits
  • Annex A2: Pre-authorization Checklist and Request for Rectal Cancer
  • Annex B: Member Empowerment Form

  • 2. Requirements for submission of claims for reimbursement (Post-surgery)
  • Annex H: Transmittal Form of Claims for the Z Benefits
  • Annex E2.1: Checklist of tranche requirements (Tranche 1)
  • Annex C2.1: Checklist of mandatory and other services
  • Annex D: Z Satisfaction Questionnaire

  • PRE-OEPRATIVE CLINICAL STAGE I BUT WITH POST-OPERATIVE PATHOLOGIC STAGE II – III
  • 1. Prior to availment of the Benefits
  • Annex A2: Pre-authorization Checklist and Request for Rectal Cancer
  • Annex B: Member Empowerment Form

  • 2. Requirements for submission of claims for reimbursement (Post-surgery)
  • Annex H: Transmittal Form of Claims for the Z Benefits
  • Annex E3.1: Checklist of tranche requirements (Tranche 1)
  • Annex C3.1: Checklist of mandatory and other services
  • Annex D: Z Satisfaction Questionnaire

  • 3. Requirements for submission of claims for reimbursement (After last cycle of chemotherapy)
  • Annex H: Transmittal Form of Claims for the Z Benefits
  • Annex E3.2: Checklist of Requirements for Reimbursement (Tranche 2)
  • Annex C3.2: Checklist of mandatory and other services
  • Annex D: Z Satisfaction Questionnaire

  • 4. Requirements for submission of claims for reimbursement (After last cycle of chemoradiotherapy)
  • Annex H: Transmittal Form of Claims for the Z Benefits
  • Annex E3.3: Checklist of Requirements for Reimbursement (Tranche 2)
  • Annex C3.3: Checklist of mandatory and other services
  • Annex D: Z Satisfaction Questionnaire

  • STAGE II – III
  • 1. Prior to availment of the Benefits
  • Annex A2: Pre-authorization Checklist and Request for Rectal Cancer
  • Annex B: Member Empowerment Form

  • 2. Requirements for submission of claims for reimbursement (Post-surgery)
  • Annex H: Transmittal Form of Claims for the Z Benefits
  • Annex E4.1: Checklist of tranche requirements (Tranche 1)
  • Annex C4.1: Checklist of mandatory and other services
  • Annex D: Z Satisfaction Questionnaire

  • 3. Requirements for submission of claims for reimbursement (After last cycle of chemotherapy)
  • Annex H: Transmittal Form of Claims for the Z Benefits
  • Annex E4.2: Checklist of Requirements for Reimbursement (Tranche 2)
  • Annex C4.2: Checklist of mandatory and other services
  • Annex D: Z Satisfaction Questionnaire
  • 4. Requirements for submission of claims for reimbursement (After last cycle of chemotherapy)
  • Annex H: Transmittal Form of Claims for the Z Benefits
  • Annex E4.3: Checklist of Requirements for Reimbursement (Tranche 2)
  • Annex C4.3: Checklist of mandatory and other services
  • Annex D: Z Satisfaction Questionnaire

  • Other Annexes
  • Annex F: Quality Indicators for the Z Benefits for Colorectal Cancers
  • Annex G: Pathway for the Z Benefits for Colon and Rectal Cancers
  • Annex I: Outcomes Report Form for Colon and Rectal Cancers

    • Kidney Transplantation
  • Annex A: Pre-authorization Checklist and Request Form
  • Annex B: Supplementary Rules on Contracting
  • Annex C: List of Essential Health Services under Z Benefits Package for Kidney Transplantation
  • Annex D: Member Empowerment Form
  • Annex E: Z Satisfaction Questionnaire
  • Annex F : Checklist of Requirements for Reimbursement
  • Annex G: Kidney Transplantation Data Registry
  • Annex H: Checklist of Services Kidney Transplantation
  • Annex I: Transmittal Form

    • Peritoneal Dialysis (PD) First
  • Annex A1: Checklist of Eligibility Criteria Adult
  • Annex A2: Checklist of Eligibility Criteria Pediatric

  • Annex B1: List of Essential Health Services for_PD Z Benefits Adult
  • Annex B2: List of Essential Health Services for PD Z Benefits Pediatric
  • Annex B3: List of Essential Health Services PD Related Ancillary Services

  • Annex C: ME Form
  • Annex D: PD Passport

  • Annex E: Letter of Intent for Transfer
  • Annex F: Checklist of Patient Transfer

  • Annex G 1A: Checklist of Requirements-CAPD Using PD Bags Adult
  • Annex G 1B: Checklist of Requirements-Exit site infection and peritonitis care Adult
  • Annex G 2A: Checklist of Requirements-CAPD Using PD Bags Pediatric
  • Annex G 2B: Checklist of Requirements-APD Using PD Bags Pediatric
  • Annex G 2C: Checklist of Requirements-Exit site infection and peritonitis care Pedia
  • Annex G 3A: Checklist of Requirements-PD related Ancillary Services (PD Catheter Insertion and Initiation)
  • Annex G 3B: Checklist of Requirements-Outpatient Treatment of PD related peritonitis
  • Annex G 3C: Checklist of Requirements PD related Ancillary Services

  • Annex H: Z Satisfaction Questionnaire

  • Annex I 1A: Checklist of Services CAPD Using PD Bags Adult
  • Annex I 1B: Checklist of Requirements-Exit site infection and peritonitis care Adult
  • Annex I 2A: Checklist of Essential Health Services Pedia
  • Annex I 2B: Checklist of Essential Health Services APD Pedia
  • Annex I 2C: Checklist of Services Exit site infection and peritonitis care pedia
  • Annex I 3A: Checklist of Services Ancillary Services-Catheter insertion and initiation
  • Annex I 3B: Checklist of Services Ancillary Services-Outpatient treatment of PD related peritonitis
  • Annex I 3C: Checklist of Services Ancillary Services-Laboratory Diagnostic Drugs Medicines

  • Annex J: Accrediting PD Z Providers
  • Annex K: Transmittal Form
  • Annex L: Home Visit Questionnaire PD Z Benefits

    • Selected Orthopedic Implants
  • I. Requirements for Pre-authorization
  • Pre-authorization Checklist and Request for Hip Arthoplasty (Annex A1)
  • Pre-authorization Checklist and Request for Hip Fixation (Annex A2)
  • Pre-authorization Checklist and Request for Pertrochanteric Fractures (Annex A3)
  • Pre-authorization Checklist and Request for Femoral and Tibial Shaft Fractures (Annex A4)
  • Pre-authorization Checklist and Request for Total Knee Replacement (Annex A5)
  • Pre-authorization Checklist and Request for Upper Extremities (Annex A6)

  • Member Empowerment Form (Annex B)

  • II. Requirements for submission of claims for reimbursement (Tranche 1)
  • Discharge Checklist for the Z Benefits - Tranche 1 (Annex C1)
  • Z Satisfaction Questionnaire (Annex D)
  • Checklist of Requirements for Reimbursement - Orthopedic Implants - Tranche 1 (Annex E1)
  • Transmittal Form of Claims for the Z Benefits (Annex H)

  • III. Requirements for submission of claims for reimbursement (Tranche 2)
  • Discharge Checklist - Orthopedic Implants - Tranche 2 (Annex C2)
  • Z Satisfaction Questionnaire (Annex D)
  • Checklist of Requirements for Reimbursement - Tranche 2 (Annex E2)
  • Transmittal Form of Claims for the Z Benefits (Annex H)

  • Other Annexes
  • Outcome Indicator (Annex F)
  • Algorithm for Orthopedic Patient Surgical Pathway (Annex G)
    • Prostate Cancer
  • I. Requirements for Pre-authorization
  • A. Pre-authorization Checklist and Request (Annex A)
  • B. Member Empowerment Form (Annex B)

  • II. Requirement for submission of claims for reimbursement

    • A. When claiming for reimbursement: Tranche 1

  • Transmittal Form (Annex H)
  • Tranche Requirements Checklist (Annex E)
  • Checklist of Mandatory Services and other services (Annex C)
  • Z Satisfaction Questionnaire (Annex D)
    • ZMORPH
  • I. Prior to availment of the Benefit
  • Pre-Authorization checklist for Expanded ZMORPH for Upper and Lower Limb Prosthesis (Annex A)
  • Member Empowerment Form (Annex B)

  • II. Requirements for submission of claims for reimbursement
  • Transmittal Form (Annex H)
  • Tranche Requirements Checklist Discharge checklist of services (Annex C)
  • Z Satisfaction Questionnaire (Annex D)
  • Checklist of Requirements for Reimbursement (Annex E)
  • Outcome Indicators (Annex G)
    • Expanded ZMORPH
  • I. Prior to availment of the Benefit
  • Pre-Authorization checklist for Expanded ZMORPH for Upper and Lower Limb Prosthesis (Annex A1)
  • Member Empowerment Form (Annex B)

  • II. When filing for Tranche 1
  • Transmittal Form (Annex H)
  • Checklist of requirements for reimbursement (Annex E1-EMORPH)
  • Discharge Checklist for Expanded ZMORPH Tranche 1 for Lower Limb Prosthesis (Annex C1.1 - EMORPH)
  • Discharge Checklist for Expanded ZMORPH Tranche 1 for Upper Limb Prosthesis (Annex C1.2 - EMORPH)
  • Z Satisfaction Questionnaire (Annex D)
  • III. When filing for Tranche 2
  • Transmittal Form (Annex H)
  • Checklist of requirements for reimbursement (Annex E2 - EMORPH)
  • Discharge Checklist for Expanded ZMORPH Tranche 2 (Annex C2-EMORPH)
  • Z Satisfaction Questionnaire (Annex D)
  • Outcome Indicators (Annex G)

    • For Expanded ZMORPH for Lower Limb Orthosis

  • I. Prior to availment of the Benefit
  • Pre-Authorization Checklist for Expanded ZMORPH for Lower Limb Orthosis (Annex A2)
  • ME Form (Annex B)
  • II. When filing for Tranche 1
  • Transmittal Form (Annex H)
  • Checklist of requirements for reimbursement (Annex E1-EMORPH)
  • Discharge Checklist for Expanded ZMORPH Tranche 1 for Lower Limb Orthosis (Annex C1.3 - EMORPH)
  • Z Satisfaction Questionnaire (Annex D)
  • III. When filing for Tranche 2
  • Transmittal Form (Annex H)
  • Checklist of requirements for reimbursement (Annex E2 - EMORPH)
  • Discharge Checklist for Expanded ZMORPH Tranche 2 (Annex C2-EMORPH)
  • Z Satisfaction Questionnaire (Annex D)
  • Outcome Indicators (Annex G)

    • For Expanded ZMORPH for Spinal Orthosis

  • I. Prior to availment of the Benefit
  • Pre-Authorization chcklist for Expanded ZMORPH for Spinal Orthosis (Annex A3)
  • ME Form (Annex B)
  • II. When filing for Tranche 1
  • Transmittal Form (Annex H)
  • Checklist of requirements for reimbursement (Annex E1-EMORPH)
  • Discharge Checklist for Expanded ZMORPH Tranche 1 for Spinal Orthosis (Annex C1.4 - EMORPH)
  • Z Satisfaction Questionnaire (Annex D)
  • Outcome Indicators (Annex G)
  • III. When filing for Tranche 2
  • Transmittal Form (Annex H)
  • Checklist of requirements for reimbursement (Annex E2 - EMORPH)
  • Discharge Checklist for Expanded ZMORPH Tranche 2 (Annex C2-EMORPH)
  • Z Satisfaction Questionnaire (Annex D)
  • Outcome Indicators (Annex G)
    • Premature or Small Newborns

    I. Prevention of Complications of Preterm Delivery

  • Checklist of Eligibility Criteria (Annex A)
  • Patient Registry Matrix (Annex B)
  • Checklist of Mandatory and Other Services for Prevention of Pre-term Delivery (Annex C1)
  • Z Satisfaction Questionnaire (Annex D)
  • Checklist of Requirements for Reimbursement (Annex E1)
  • Coordinated Referral and Transfer Form (Annex G)
  • Transmittal Form (Annex H)
  • WHO Partograph (Annex I)
  • Other High Risks Conditions (Annex P)

    • II. Premature or Small Baby

  • Checklist of Eligibility Criteria (Annex A)
  • Patient Registry Matrix (Annex B)
  • Checklist of Mandatory and Other Services for Premature and Small Baby (Annex C2)
  • Z Satisfaction Questionnaire (Annex D)
  • Checklist of Requirements for Reimbursement (Annex E2)
  • Coordinated Referral and Transfer Form (Annex G)
  • Transmittal Form (Annex H)
  • WHO Partograph (Annex I)
  • Essential Intrapartum and Newborns care (EINC) (Annex J)
  • Kangaroo Care Protocol Checklist (Annex K)
  • Field Survey Tool (Annex L)
  • Pre-Discharge Checklist (Annex M)
  • Pre-Discharge Counselling Services Checklist (Annex M1)
  • Post Mortem Care, Bereavement Support and Counselling Services Checklist (Annex M2)
  • Certificate of Medical Futility (Annex N)
  • Indicators for Medical Futility (Annex O)
    • Z Benefits for Children with Mobility Impairment
  • Prior to availment of the Z Benefits
  • A. Pre-authorization Checklist and Request (Annex A)
  • B. Member Empowerment Form (Annex B)

  • II. Assistive Device Provision, Training and Rehabilitation

    • A. When claiming for assessment, prescription, casting and measurement of the assistive device (1st Tranche)

  • Transmittal Form (Annex H)
  • Checklist of Requirements for Reimbursement (Tranche 1) (Annex E1)
  • Checklist of Mandatory Services Z Benefits for Children with Mobility Impairment (Tranche 1) (Annex C1)
  • Z Satisfaction Questionnaire (Annex D)

    • B. When claiming for assistive device fitting and mobility training (2nd Tranche)

  • Transmittal Form (Annex H)
  • Checklist of Requirements for Reimbursement (Tranche 2) (Annex E2)
  • Checklist of Mandatory Services Z Benefits for Children with Mobility Impairment (Tranche 2) (Annex C2)
  • Z Satisfaction Questionnaire (Annex D)
  • Certificate of Completed Training on the Safe and Functional use of the Device (Annex J)

    • C. When claiming for rehabilitation services (3rd tranche)

  • Transmittal Form (Annex H)
  • Checklist of Mandatory Services Z Benefits for Children with Mobility Impairment (Tranche 3) (Annex E3)
  • Z Satisfaction Questionnaire (Annex D)
  • Certificate of outcomes after rehabilitation session (Annex K)

  • III. Assistive device repair, replacement and yearly service

  • Transmittal Form (Annex H)
  • Checklist of Requirement for Reimbursement Mobility Impairment Yearly Services and Replacement (Annex E)
  • Checklist of Mandatory Services Z Benefits for Children with Mobility Impairment Yearly Services and Replacement (Annex C)
  • Z Satisfaction Questionnaire (Annex D)
    • Z Benefits for Children with Developmental Disabilities
  • I. Prior to availment of the Z Benefits
  • A. Pre-authorization Checklist and Request (Annex A)
  • B. Member Empowerment Form (Annex B)

  • II. Initial Assessment

    • A. When claiming for Initial Assessment from a Medical Specialist (1st Tranche)

  • Transmittal Form (Annex H)
  • Checklist of Requirements for Reimbursement (Tranche 1) (Annex E1)
  • Checklist of Mandatory Services Z Benefits for Children with Developmental Disabilities (Tranche 1) (Annex C1)
  • Z Satisfaction Questionnaire (Annex D)
  • Certificate of Assessment and recommendations(Annex J)

    • B. When claiming for Initial Assessment from a Rehabilitation Therapist/Allied Health Professional (2nd Tranche, if applicable)

  • Transmittal Form (Annex H)
  • Checklist of Requirements for Reimbursement (Tranche 2) (Annex E2)
  • Checklist of Mandatory Services Z Benefits for Children with Developmental (Tranche 2) (Annex C2)
  • Z Satisfaction Questionnaire (Annex D)
  • Certificate of Assessment and recommendations(Annex J)

  • III. When claiming for Rehabilitation Tranches (up to 9 claims)
  • Transmittal Form (Annex H)
  • Checklist of Requirements for Reimbursement Z Benefits for Children with Developmental Disabilities Rehabilitation Therapy (Annex E)
  • Checklist of Mandatory Services Z Benefits for Children with Developmental Disabilities Rehabilitation Therapy (Annex C)
  • Z Satisfaction Questionnaire (Annex D)

  • IV. Discharge Assessment

    • A. When claiming for Discharge Assessment from a Rehabilitation Therapist/Allied Health Professional (1st tranche, if applicable)

  • Transmittal Form (Annex H)
  • Checklist of Requirements for Reimbursement (Tranche 1) (Annex E1)
  • Checklist of Mandatory Services Z Benefits for Children with Developmental Disabilities (Tranche 1) (Annex C1)
  • Z Satisfaction Questionnaire (Annex D)
  • Certificate of Assessment and recommendations(Annex J)

    • B. When claiming for Discharge Assessment from a Medical Specialist (2nd tranche)

  • Transmittal Form (Annex H)
  • Checklist of Requirements for Reimbursement (Tranche 2) (Annex E2)
  • Checklist of Mandatory Services Z Benefits for Children with Developmental (Tranche 2) (Annex C2)
  • Z Satisfaction Questionnaire (Annex D)
  • Certificate of Assessment and recommendations(Annex J)
    • Z Benefits for Children with Hearing Impairment
  • I. Prior to availment of the Z Benefits
  • A. Pre-authorization Checklist and Request (Annex A)
  • B. Member Empowerment Form (Annex B)

  • II. Initial Assessment when claiming for Initial Assessment (1st Tranche)
  • Transmittal Form (Annex H)
  • Checklist of Requirements for Reimbursement Assessment (Tranche 1) (Annex E1)
  • Checklist of Mandatory Services Z Benefits for Children with Impairment Hearing (Tranche 1) (Annex C1)
  • Z Satisfaction Questionnaire (Annex D)
  • Certificate of Completed Hearing Aid Verification (Annex J)

  • III. When claiming for reimbursement hearing aid provision (Tranche 2)
  • Transmittal Form (Annex H)
  • Checklist of Requirements for Reimbursement Hearing aid provision (Tranche 2) (Annex E2)
  • Checklist of Mandatory Services Z Benefits for Children with Hearing Impairment (Annex C2)
  • Z Satisfaction Questionnaire (Annex D)
  • Certificate of Completed Hearing Aid Verification (Annex J)

  • IV. When claiming for reimbursement for ear-mold refitting
  • Transmittal Form (Annex H)
  • Checklist of Requirements for Reimbursement for ear-mold refitting (Annex E3)
  • Checklist of Mandatory Services Z Benefits f or ear-mold refitting (Annex C3)
  • Z Satisfaction Questionnaire (Annex D)

  • V. When claiming for hearing aid replacement
  • Checklist of Mandatory Services Z Benefits hearing aid replacement (Annex C)
  • Certification of completed speech therapy sessions (Annex K)
    • Z Benefits for Visual Disabilities
  • I. Prior to availment of the Z Benefits
  • A. Pre-authorization Checklist and Request (Annex A)
  • B. Member Empowerment Form (Annex B)

  • II. Category 1
  • A. Initial Assessment and Intervention
  • 1. When claiming for initial assessment and intervention (Tranche 1)
  • Transmittal Form (Annex H)
  • Checklist of Requirements for Reimbursement (Annex E1.1)
  • Checklist of Mandatory Services (Annex C1.1)
  • Z Satisfaction Questionnaire (Annex D)

  • 2. When claiming for appropriate assistive device (add-on) (Tranche 2)
  • Transmittal Form (Annex H)
  • Checklist of requirements for reimbursement (Annex E2.1)
  • Checklist of Mandatory Services (Annex C2.1)
  • Z Satisfaction Questionnaire (Annex D)

  • 3. When claiming for other services including training and rehabilitation (Tranche 3)
  • Transmittal Form (Annex H)
  • Checklist of requirements for reimbursement (Annex E3.1)
  • Certificate of Training and Rehabilitation (Annex J)
  • Z Satisfaction Questionnaire (Annex D)

  • B. Yearly Diagnostics
  • Checklist of Requirements for Reimbursement (Annex E.4)
  • Checklist of Mandatory Services (Annex C.3)
  • Z Satisfaction Questionnaire (Annex D)

  • III. Category 2, 3, 4
  • A. Initial Assessment and Intervention
  • 1. When claiming for initial assessment and intervention (Tranche 1)
  • Transmittal Form (Annex H)
  • Checklist of Requirements for Reimbursement (Annex E1.2)
  • Checklist of Mandatory Services (Annex C1.2)
  • Z Satisfaction Questionnaire (Annex D)

  • 2. When claiming for appropriate assistive device (add-on) (Tranche 2)
  • Transmittal Form (Annex H)
  • Checklist of requirements for reimbursement (Annex E2.2)
  • Checklist of Mandatory Services (Annex C2.2)
  • Z Satisfaction Questionnaire (Annex D)

  • 3. When claiming for other services including training and rehabilitation (Tranche 3)
  • Transmittal Form (Annex H)
  • Checklist of requirements for reimbursement (Annex E3.2)
  • Certificate of Training and Rehabilitation (Annex J)
  • Z Satisfaction Questionnaire (Annex D)

  • B. Yearly Diagnostics
  • Checklist of Requirements for Reimbursement (Annex E.4)
  • Checklist of Mandatory Services (Annex C.3)
  • Z Satisfaction Questionnaire (Annex D)

  • C. Electronic assistive device replacement
  • Checklist of Mandatory Services (Annex C.4)
  • Z Satisfaction Questionnaire (Annex D)

  • IV. Category 5
  • A. Initial Assessment and Intervention
  • 1. When claiming for initial assessment and intervention (Tranche 1)
  • Transmittal Form (Annex H)
  • Checklist of Requirements for Reimbursement (Annex E1.3)
  • Checklist of Mandatory Services (Annex C1.3)
  • Z Satisfaction Questionnaire (Annex D)

  • 2. When claiming for appropriate assistive device (add-on) (Tranche 2)
  • Checklist of requirements for reimbursement (Annex E2.3)
  • Checklist of Mandatory Services (Annex C2.3)
  • Z Satisfaction Questionnaire (Annex D)

  • 3. When claiming for other services including training and rehabilitation (Tranche 3)
  • Checklist of requirements for reimbursement (Annex E3.3) Certificate of Training and Rehabilitation (Annex J)
  • Z Satisfaction Questionnaire (Annex D)

  • B. Yearly Follow up Consultations
  • Checklist of Requirements for Reimbursement (Annex E.4)
  • Checklist of Mandatory Services (Annex C.3)
  • Z Satisfaction Questionnaire (Annex D)

  • C. Electronic assistive device replacement
  • Checklist of Mandatory Services (Annex C.4)
  • Z Satisfaction Questionnaire (Annex D)
    • Z Benefits for Open Heart Surgeries
  • Annex A.1 - Preauthorization_Checklist_and_Request_Form_CABG
  • Annex A.2 - Preauthorization_Checklist_and_Request_Form_VSD_or_VSD_with_Associated_Conditions
  • Annex A.3 - Preauthorization_Checklist_and_Request_Form_TOF_or_VSD_with_Severe_Pulmonary_Stenosis
  • Annex B - Supplementary_Rules_in_Accrediting_and_Contracting_Health_Facilities
  • Annex C.1 - List_of_Essential_Health_Services_CABG
  • Annex C.2 - List_of_Essential_Health_Services_VSD_or_VSD_with_Associated_Conditions
  • Annex C3 - List_of_Essential_Health_Services_TOF_or_VSD_with_Pulmonary_Stenosis
  • Annex D - Member_Empowerment_(ME)_Form
  • Annex E - Z_Satisfaction_Questionnaire
  • Annex F.1 - Checklist_of_Requirements_for_Open_Heart_Surgery
  • Annex F.2 - Checklist_of_Requirements_for_Post-Cardiac_Surgery_Services
  • Annex G - Transmittal_Form
  • Annex H.1 - Checklist_of_Services_for_CABG
  • Annex H.2 - Checklist_of_Services_for_VSD_or_VSD_with_Associated_Conditions
  • Annex H.3 - Checklist_of_Services_for_TOF_and_VSD_with_Severe_Pulmonary_Stenosis
  • Annex H.4 - Checklist_of_Services_for_Post_Cardiac_Surgery_Services
    • Z Benefits Package for Heart Valve Repair and/or Replacement for Valvular Heart Disease
  • Annex A.1 - Pre-authorization_Heart_Valve_Surgery_for_Adult
  • Annex A.2 - Pre-authorization_ Heart_Valve_Surgery_for_Pediatric
  • Annex_B - Supplementary_Rules_in_Accrediting_and_Contracting_Health_Facilities
  • Annex_C - List_of_Essential_Health_Services
  • Annex_D - Member_Empowerment_(ME)_Form
  • Annex_E - Z_Satisfaction_Questionnaire
  • Annex F - Checklist_of_Requirements
  • Annex G - Transmittal_Form
  • Annex H - Checklist_of_Essential_Health_Services
    • Z Benefits Package for Post-Kidney Transplantation Services in Adults
  • A. Enrollment
  • 1. Kidney Transplant Recipient - Adult
  • 1.1. Annex A.1.: Pre-authorization Checklist and Request Form for Kidney Transplant Recipient - Adult
  • 1.2. Annex D: Member Empowerment Form (ME Form)
  • 2. Kidney Transplant - Living Donor
  • 2.1. Annex A.2.: Pre-authorization Checklist and Request Form for Living Kidney Donor

  • B. Claims Filing and Reimbursement for Kidney Transplant Recipient - Adult
  • 1. Annex J: Transmittal Form
  • 2. Annex E.1: Checklist of Essential Health Services - Kidney Transplant Recipient - Adult
  • 3. Annex I.1.: Checklist of Requirements for Reimbursement - Kidney Transplant Recipient - Adult
  • 4. Annex F: Post-Kidney Transplant Passport
  • 5. Annex K: Z Satisfaction Questionnaire

  • C. Claims Filing and Reimbursement for Kidney Transplant - Living Donor
  • 1. Annex J: Transmittal Form
  • 2. Annex E.2.: Checklist of Essential Health Services - Living Kidney Donor
  • 3. Annex I.2.: Checklist of Requirements for Reimbursement - Living Kidney Donor

  • D. Documentary Requirements for Patient Transfer
  • 1. Annex G: Letter of Intent for Patient Transfer of Care to a Referral Contracted Health Facility
  • 2. Annex H: Checklist of Patient Transfer to the Referral Contracted Health Facility
  • E. Other Annexes
  • 1. Annex B: Supplementary Rules in Accrediting and Contracting Health Facilities
  • 2. Annex C: List of Essential Health Services for Post-Kidney Transplantation Services in Adults
    • Z Benefits Package for Post-Kidney Transplantation Services in Children
  • A. Enrollment
  • 1. Kidney Transplant Recipient - Children
  • 1.1. Annex A.1.: Pre-authorization Checklist and Request Form for Kidney Transplant Recipient - Pediatric
  • 1.2. Annex D: Member Empowerment Form (ME Form)
  • 1. Kidney Transplant Recipient - Children
  • 2.1. Annex A.2.: Pre-authorization Checklist and Request Form for Living Kidney Donor

  • B. Claims Filing and Reimbursement for Kidney Transplant Recipient - Children
  • 1. Annex J: Transmittal Form
  • 2. Annex E.1: Checklist of Essential Health Services - Kidney Transplant Recipient - Pediatric
  • 3. Annex I.1.: Checklist of Requirements for Reimbursement - Kidney Transplant Recipient - Pediatric
  • 4. Annex F: Post-Kidney Transplant Passport
  • 5. Annex K: Z Satisfaction Questionnaire

  • C. Claims Filing and Reimbursement for Kidney Transplant - Living Donor
  • 1. Annex J: Transmittal Form
  • 2. Annex E.2.: Checklist of Essential Health Services - Living Kidney Donor
  • 3. Annex I.2.: Checklist of Requirements for Reimbursement - Living Kidney Donor

  • D. Documentary Requirements for Patient Transfer
  • 1. Annex G: Letter of Intent for Patient Transfer of Care to a Referral Contracted Health Facility
  • 2. Annex H: Checklist of Patient Transfer to the Referral Contracted Health Facility

  • E. Other Annexes
  • 1. Annex B: Supplementary Rules in Accrediting and Contracting Health Facilities
  • 2. Annex C: List of Essential Health Services for Post-Kidney Transplantation Services - Pediatric


    • Self-Assessment Tools
  • Secondary Prevention of Rheumatic Fever/Rheumatic Heart Disease
  • Outpatient Benefit Package for Severe Acute Malnutrition (SAM)
  • Benefit Package for Physical Medicine, Rehabilitation Services, and Assistive Devices (for Hospital-base)
  • Mental Health Package
  • General Mental Health Services
  • Specialty Mental Health Services



    • 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)

    • Benefits Package for Physical Medicine, Rehabilitation Services, and Assistive Mobility Devices
  • Annex A - Checklist of Eligibility Criteria PMRS
  • Annex B - Member Empowerment Form
  • Annex C1 - Preauthorization Checklist and Request Form for Wheelchairs
  • Annex C2 - Preauthorization Checklist and Request form for other Assistive Mobility Devices
  • Annex D - List of Essential Health Services
  • Annex E - Checklist of Essential Health Services
  • Annex F1 - Checklist of Requirements for Reimbursement Assessment
  • Annex F2 - Checklist of Requirements for Reimburesement Rehabilitation Services
  • Annex F3 - Checklist of Requirements for Reimbursement Laboratory and Diagnostic Test and Drugs Medicines
  • Annex F4 - Checklist of Requirements for Reimbursement Assistive Mobility Devices
  • Annex G - Transmitttal Form
  • Annex H - Satisfaction Questionnaire
  • Annex I - Pilot testing of the PMRS

    • Outpatient Therapeutic Care (OTC) Benefits Package for Severe Acute Malnutrition (SAM) for Children Sixty (60) Months Old and Below
  • A. Enrollment
  • 1. Annex A: Checklist of Eligibility Criteria for OTC Benefits Package for SAM
  • 1. Annex A - Checklist of Eligibility Criteria for OTC Benefits Package for SAM

  • B. Claims Filing and Reimbursement for SAM (Children 0 to 6 months old)
  • 1. Annex B.1 – Checklist of Mandatory and Other Services (0 to less than 6 months Old) Tranche 1
  • 2. Annex B.2 – Checklist of Mandatory and Other Services (0 to less than 6 months Old) Tranche 2
  • 3. Annex D.1 – Checklist of Requirements for Reimbursement (0 to less than 6 Months Old) Tranche 1
  • 4. Annex D.2 – Checklist of Requirements for Reimbursement (0 to less than 6 Months Old) Tranche 2
  • 5. Annex E – OTC SAM Satisfaction Questionnaire
  • 6. Annex F – Transmittal Form for the OTC Benefits Package for SAM
  • 7. Annex G.1 – Sample Claim Form 2 (0 to less than 6 Months Old) Tranche 1
  • 8. Annex G.2 – Sample Claim Form 2 (0 to less than 6 Months Old) Tranche 2
  • 9. Annex H – Ready To Use Therapeutic Food RUTF Ration Card
  • 10. Annex I – SAM Registration Log
  • 11. Annex J – OTC SAM Treatment Record Chart

  • C. Claims Filing and Reimbursement for SAM (Children 6 to 60 months old)
  • 1. Annex B.3 – Checklist of Mandatory and Other Services (6 to 60 months Old) Tranche 1
  • 2. Annex B.4 – Checklist of Mandatory and Other Services (6 to 60 months Old) Tranche 2
  • 3. Annex D.3 – Checklist of Requirements for Reimbursement (6 to 60 Months Old) Tranche 1
  • 4. Annex D.4 – Checklist of Requirements for Reimbursement (6 to 60 Months Old) Tranche 2
  • 5. Annex E – OTC SAM Satisfaction Questionnaire
  • 6. Annex F – Transmittal Form for the OTC Benefits Package for SAM
  • 7. Annex G.3 – Sample Claim Form 2 (6 to 60 Months Old) Tranche 1
  • 8. Annex G.4 – Sample Claim Form 2 (6 to 60 Months Old) Tranche 2
  • 9. Annex H – Ready To Use Therapeutic Food RUTF Ration Card
  • 10. Annex I – SAM Registration Log
  • 11. Annex J – OTC SAM Treatment Record Chart

  • Other Annexes
  • Annex C – Minimum Requirements for Accreditation of Health Facilities for OTC SAM
  • Annex K – OTC ITC SAM Referral Form
  • Annex L – List of Performance Indicators for OTC SAM

  • Annex A: Standards for Accreditation of PhilHealth Konsulta Facilities

  • Self-Assessment/ Accreditation Tool PhilHealth YAKAP provider

  • Annex B.1 Health Human Resource Survey Tool for PhilHealth Konsulta Facility
  • Annex B.2 Checklist of PhilHealth Konsulta Drugs and Its Preparations
  • Annex B.3 Checklist of PhilHealth Konsulta Laboratories and Diagnostic Services
  • Annex C. Procedures and Documentary Requirements for Accreditation of PhilHealth Konsulta Providers
  • Annex D.1 Certification of Service Delivery Support (Laboratory and Diagnostic Services)
  • Annex D.2 Certification of Service Delivery Support (Medicines)
  • Annex E. Non-disclosure Agreement

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  • Z Benefits for Premature and Small Newborns
    Laking pasasalamat ni Gng. Mary Grace Calamba ng Bonbon, Lower Loboc, Bohol sa PhilHealth Z Benefits para sa premature and small babies. Alamin ang kanyang kwento.
  • Z Benefits for Premature and Small Newborns
    Nabigyan ng Gov. Celestino Gallares Memorial Hospital ang 41 premature babies ng serbisyong medikal sa ilalim ng Z Benefits para sa premature and small babies simula Disyembre 2018. Ang Gallares ang kauna-unahang hospital sa buong bansa na naging contracted para sa nasabing benepisyo.
  • Z Benefits for Premature and Small Newborns
    Panoorin ang kwento ng mag-inang Mary Grace at Matt Franco Calamba ng Bonbon, Lower Loboc, Bohol, na naka-avail ng Z Benefits para sa premature at small babies.

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