PhilHealth

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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)

  • Dialysis Database

  • Registration Form
  • Certification on Diagnosis and Management of CKD Stage 5

  • Payment

  • PPPS: PhilHealth Premium Payment Slip

  • Employers

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

  • 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
  • Collecting Agents

  • CAAF: Collecting Agents Accreditation Form

  • Health IT Partners

  • e-Claims Implementation Guide »

  • Health Care Professionals

  • Requirements for Health Care Professional Accreditation
  • Performance Commitment For Health Care Professionals per PhilHealth Circular 013-2015
  • Health Care Professional Provider Data Record

  • Health Care Facilities

  • PDR: Provider Data Record
  • MMHR: Monthly Mandatory Hospital Report
  • SOI: Statement of Intent (Initial/Re-accreditation)

  • MOP: Manual of Procedures of the New Accreditation Process (PEACHeS)

  • Performance Commitment:
  • Performance Commitment for Health Care Institutions (Revision 3)


  • Self-Assessment Tools

    Pre-Authorization and Claims Reimbursement

    Coronary Artery Bypass Graft Surgery
    Tetralogy of Fallot
    Ventricular Septal Defect Surgery
    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)

  • For Expanded Z MORPH 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)

  • For Expanded Z MORPH 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)
  • 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)

  • Cervical Cancer
    Selected Orthopedic Implants
    Colon Cancer
    Rectal 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. Rectum Cancer Stage I (clinical and pathologic stage):
  • When claiming for reimbursement: Rectum Cancer Stage I (clinical and pathologic stage) - (Single tranche)

  • Transmittal Form (Annex H)
  • Tranche Requirements Checklist (Annex E1.1)
  • Checklist of Mandatory Services and other services (Annex C1.1)
  • Z Satisfaction Questionnaire (Annex D)

  • B. Rectum cancer pre-operative clinical stage I with post-operative pathologic stage II - III
  • 1. When claiming for Tranche 1, Rectum cancer pre-operative clinical stage I with post-operative pathologic stage II - III

  • Transmittal Form (Annex H)
  • Tranche Requirements Checklist (Annex E1.2)
  • Checklist of Mandatory Services and other services (Annex C1.2)
  • Satisfaction Questionnaire (Annex D)
  • 2. When claiming for Tranche 2, Rectum cancer pre-operative clinical stage I with post-operative pathologic stage II - III

  • Transmittal Form (Annex H)
  • Tranche Requirements Checklist (Annex E2.2)
  • Checklist of Mandatory Services and other services (Annex C2.2)
  • Satisfaction Questionnaire (Annex D)
  • 3. When claiming for Tranche 3, Rectum cancer pre-operative clinical stage I with post-operative pathologic stage II - III

  • Transmittal Form (Annex H)
  • Tranche Requirements Checklist (Annex E3.2)
  • Checklist of Mandatory Services and other services (Annex C3.2)
  • Satisfaction Questionnaire (Annex D)

  • C. Rectum cancer pre-treatment clinical stage II - III
  • 1. When claiming for Tranche 1, Rectum cancer pre-treatment clinical stage II - III

  • Transmittal Form (Annex H)
  • Tranche Requirements Checklist (Annex E1.3)
  • Checklist of Mandatory Services and other services (Annex C1.3)
  • Z Satisfaction Questionnaire (Annex D)
  • 2. When claiming for Tranche 2, Rectum cancer pre-treatment clinical stage II - III

  • Transmittal Form (Annex H)
  • Tranche Requirements Checklist (Annex E2.3)
  • Checklist of Mandatory Services and other services (Annex C2.3)
  • Z Satisfaction Questionnaire (Annex D)
  • 3. When claiming for Tranche 3, Rectum cancer pre-treatment clinical stage II - III

  • Transmittal Form (Annex H)
  • Tranche Requirements Checklist (Annex E3.3)
  • Checklist of Mandatory Services and other services (Annex C3.3)
  • Z Satisfaction Questionnaire (Annex D)
  • Acute Lymphocytic Leukemia
    Breast 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 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. For mortalities and "lost to follow up" patients (to be submitted as attachment to the claims for tranche 2 if services were provided)

  • Breast Cancer Medical Records Summary Form (Annex O)
  • Prostate Cancer
    Kidney Transplantation
    Peritoneal Dialysis (PD) First
    Z Benefits for Prevention of Preterm Delivery
    Z Benefits for Preterm and Small Baby
    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)

  • Member Empowerment Form (ME Form)