This form may be reproduced and
Republic of the Philippines is NOTFORSALE
PHILIPPINE HEALTHINSURANCECORPORATION
Citystate Centre 709 Shaw Boulevard, Pasig City
Call Center (02) 441-7442 • Trunkline (02) 441-7444
www.philhealth.gov.ph
CSF
(Claim Signature Form)
email: actioncenter@philhealth.gov.ph
RevisedSeptember 2018
IMPORTANT REMINDERS: #1
Series L-L......L--,--,_jL-J_J...._-,-_j__L..l-...J.......J
PLEASEWRITEINCAPITALLETIERS ANDCHECK THEAPPROPRIATE 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: OJ-LI_L_L_L_L_L_L_L_L...JI-O
2. Name of Member: 3. Member Date of Birth:
[IJ-[IJ-I
LastName FirstName Name Extension Middle Name month day '--'-y..J.ea-r..l--
(JR(SRjlll) (ex:DELA CRUZ JUAN JR SIPAG)
4. PhilHealth Identification Number (PIN) of Dependent: [IJ -LI.....J........J........J........J........J........J........J........J..._JI-O
5. Name of Patient: 6. Relationship to Member:
LastName FirstName Name Extension MiddleName
o child 0 parent 0 spouse
(JRjSRjlll) (ex: DELA CRUZ JUAN JR SIPAG)
7. Confinement Period: S. Patient Date of Birth:
a. DateAdmitted: ITJ-ITJ-I b. DateDischarged:ITJ-ITJ-I ITJ-ITJ-I
month day L-.l-y...Lea-r-'-...J month day '-..L..y7ea"'r...J.......J mo nth day '--'-y""ea"'r..l-_J
9.CERTIFICATlON OF MEMBER:
Under the penalty of law, I attest that the information Iprovided in this Form are true and accurate to the best of my knowledge.
D
SignatureOverPrinted Nameof Member SignatureOverPrinted Name of Member'sRepresentative
DateSigned ITJ-ITJ-I DateSigned ITJ-ITJ-LI......L--'_'--
month
If member/representativeis unable to write.
put right thumbmark. Member/Representative
day L-''-y-:':ea'''''r
J,........J
Relationshipof the
representativeto the member
month
Spouse
day
o
0
Child
year
Sibling
0
0
0 Parent
Others.Specify-------
should be assistedby an HCIrepresentative.
Checkthe appropriate box.
o Reasonfor signing on o Member is incapacitated
Member 0 Representative behalf of the member o Other reasons:============
PART 11- EMPLOYER'S CERTIFICATION 'I' II I "I ,) I,
l.PhilHealth Employer Number (PEN): [lliJ-1 0121716131 014IaI31-[§J 2. Contact No.: __ _,5~a,¥0_:_-->!C5a~a&a~
__
3. Business Name: ACCENIlJRE INC
BusinessNameof Employer
4. CERTIFICATION OF EMPLOYER:
monthly premium contributions plus at least 6 months contributions preceding the 3 months qualifying contributions within 12
.hpFu." <in"0,( corfinement (sufficient regularity) have been regularly remitted to PhilHealth. Moreover, the information supplied by the member or
re"rresent'Otilve)jfi'f.~~'l'1:~;ist'mt with our available records."
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.
Ihereby 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.
Date Signed ITJ-ITJ-LI __J,__J_jL,_
SignatureOver Printed Name of Member/Patient/Authorized Representative month day year
o 0 0
D
If member/representativeis unable to write. Relationshipof the Spouse Child Parent
put right thumbmark. Member/Representative
should be assistedby an HCIrepresentative.
representativeto the patient 0 Sibling OOthers, Specify _
Checkthe appropriate box.
o Patient 0 Representative
Reasonfor signing on
behalf of the patient
o
o Patient is incapacitated
Other reasons'
PART IV - HEALTH CARE PROFESSIONAL INFORMATION
Accreditation No. LL~__JI-~I DateSigned ITJ-ITJ-I
~-'-J.........JL--,--,I-O month day L-.l-ye..La-r-'---'
SignatureOverPrinted Name
Accreditation No. ~_L..l-...JL_I-I 0
1-
SignatureOverPrinted Name
DateSigned ITJ-ITJ-LI-L_""'~_
month day year
Accreditation No. L.......L...JL-'_I-I 1-0 SignatureOverPrinted Name
DateSigned ITJ-ITJ-LI---'.--,--,,-
month day year
PART V - PROVIDER INFORMATION AND CERTIFICATION
ICD 10 or RVS Code: I. FirstCaseRate _ 2. SecondCaseRate _
1.PhilHealth Benefits:
Icertify that servIces rendered were recorded in the patient's chart and health core institution records and that the herein information given are true and correct.
DateSigned ITJ-ITJ-I 1 1 1
SignatureOver Printed Nameof Authorized HCIRepresentative Official Capacity/Designation month day year
This form may be reproduced and
is NOT FORSALE
Republic of the Philippines
PHILIPPINE HEALTHINSURANCECORPORATION
Citystate Centre 709 Shaw Boulevard. Pasig City
Call Center (02) 441-7442 • Trunkline (02) 441-7444
CF-l
(Claim Form 1)
www.philhealth.gov.ph Revised September 2018
email: actioncenter@philhealth.gov.ph
Series # I
IMPORTANT REMINDERS:
PLEASEWRITEIN CAPITALLETIERS AND CHECK THE APPROPRIATEBOXES.
For local availment, this form together with other Phil Health claim forms and other supporting documents should be filed within 60 days from date of discharge.
For availment of benefits abroad, this form together with other supporting documents should be filed within 180 days from date of discharge.
Representative of the Health Care Institutions (HCI)shall assist the member/authorized representative in filling out this form.
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.
PARTI - MEMBERINFORMATION
1.PhilHealth Identification Number (PIN) of Member: CD -LI-L.-L.-L.-L.-L.-L.-L.-L._jl- D
2. Nameof Member: 3.Date of Birth:
CD-CD-I,-,-,-,--,
Last Name First Name Name Extension Middle Name month day year
(JRISR/III) (ex:DELACRUZ JUAN JR SIPAG)
4. Mailing Address: 5. Sex: D Male D Female
Unit/Room No,fFloor Building Name Lot/Blk/House/Bldg.NO Street Subdivision/Village
Barangay City/Municipality Province Country Zip Code
6.Contact Information:
Landline No. (Area Code + Tel. No.) Mobile No. Email Address
7.Patient is the member? D Yes,Proceed to Part III D No, Proceed to Part II
PART" - PATIENT INFORMATION 1 ,I" t,', '
1.PhilHealth Identification Number (PIN) of Dependent: CD-LI ___,L____,L____,L____,L____,L____,L____,L____,L_.....JI-D
2. Nameof Patient: 3.Date of Birth:
Last Name First Name Name Extension MiddleName
CD-[TI-L-I L-L.....J__j
month day year
(JRISR/III) (ex: DELACRUZ JUAN JR SIPAG)
4. Relationship to Member: D Child D Parent D Spouse 5. Sex: D Male D Female
PARTIII - MEMBERCERTIFICATION
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.
Signature Over Printed Name of Member Signature Over Printed Name of Member's Representative
Date Signed CD -CD -I.._..__.J.._--'-...J Date Signed CD-CD-IL_L--'-...I........J
month day year month day year
D D D
D
If member/representative is unable to write, Relationship of the Spouse Child Parent
put right thumbmark. Member/Representative
should be assisted by an HCI representative.
representative to the member D Sibling D Others, Specify _
Check the appropriate box. Reason for signing on D Member is incapacitated
D Member D Representative behalf of the member D Other reasons: ------------
PARTIV - EMPLOYER'SCERTIFICATION
I.PhilHealth Employer Number (PEN): I}IQ]-I 0 121716 1310141 aI31-[§J 2.Contact No.: _~5L1.8L1.0L5o.lJ8",8",8",-- _
3.BusinessName:
ACCENTURE INC
Business Name of Employer
4.CERTIFICATION
OFEMPLOYER:
contributions plus at least 6months contributions preceding the 3 months qualifying contributions within 12
first.8l.'f!lc'f<J,ln(i'ne,ne'lt(!,ufficie'ntl'eq"Ia.-ityjhave been regularly remitted to PhilHealth. Moreover, the information supplied by the member or
HR Service Delivery SeniorAnal~L DateSigned CD-CD-I.._..__.J.._--'-...J
Official CapaCity/Designation month
Date Received:
LHIO/PRO Signature Over Printed Name
