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    Haykal Salomon Lorena
    This document is a PhilHealth claim form that must be filed within 60 days of discharge. It collects information about the patient and member, including their identification numbers, names, addresses, dates of birth, civil status, and relationship. The member and employer must certify that the required monthly contributions were paid in the six months prior to confinement. Supporting documentation is required depending on the member's type, such as receipts, forms, or certifications.

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    CF 1

    Uploaded by

    Haykal Salomon Lorena
    3K views2 pages
    This document is a PhilHealth claim form that must be filed within 60 days of discharge. It collects information about the patient and member, including their identification numbers, names, addresses, dates of birth, civil status, and relationship. The member and employer must certify that the required monthly contributions were paid in the six months prior to confinement. Supporting documentation is required depending on the member's type, such as receipts, forms, or certifications.

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    This document is a PhilHealth claim form that must be filed within 60 days of discharge. It collects information about the patient and member, including their identification numbers, names, addresses, dates of birth, civil status, and relationship. The member and employer must certify that the required monthly contributions were paid in the six months prior to confinement. Supporting documentation is required depending on the member's type, such as receipts, forms, or certifications.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    3K views2 pages

    CF 1

    Uploaded by

    Haykal Salomon Lorena
    This document is a PhilHealth claim form that must be filed within 60 days of discharge. It collects information about the patient and member, including their identification numbers, names, addresses, dates of birth, civil status, and relationship. The member and employer must certify that the required monthly contributions were paid in the six months prior to confinement. Supporting documentation is required depending on the member's type, such as receipts, forms, or certifications.

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    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    This form may be reproduced and is NOT FOR SALE

    PHILHEALTH
    CLAIM FORM 1
    Revised May 2000
    NOTE: THIS FORM TOGETHER WITH CLAIM FORM 2 SHOULD BE FILED WITH PHILHEALTH WITHIN 60 CALENDAR DAYS FROM DATE OF DISCHARGE.
    PART I - MEMBER'S CERTIFICATION (Member to Fill in All Items/Indigent to be Assisted by Hospital Representative)
    1. Type of Membership Employed: Private Sector Gov't. Sector Individually paying: Self-employed OFW Others OWWA
    Indigent Retiree/Pensioner: SSS GSIS Military Judiciary
    Identification No.

    2. Name of Member 3. Date of Birth


    Last Name
    m m d d y y y y
    First Name 4. Civil Status 5. Sex

    Single Separated Male


    Middle Name
    Married Widow/er Female

    6. Address of Member
    No., Street Barangay

    Municipality/City Province Zip Code

    7. Name of Spouse
    Last Name First Name

    Middle Name
    Not Applicable

    8. Name of Patient Patient is the Member 9. Date of Birth


    Last Name
    m m d d y y y y
    First Name
    10. Age 11. Sex
    Male
    Middle Name
    Female
    12. Relationship of Patient to Member ( Check applicable box if patient is a dependent )
    Legitimate spouse who is not an NHIP Member. Parent who is 60 years old and above, not an NHIP member/retiree/pensioner and
    Unmarried and unemployed, legitimate, legitimated, wholly dependent on me for support.
    acknowledged and illegitimate or legally adopted/step Unmarried child 21 years old & above with physical/ mental disability, congenital or
    child, below 21 years old. acquired and wholly dependent on me for support.
    13. CERTIFICATION of MEMBER: I certify that the foregoing information are true and correct and that the three(3) applicable monthly contributions had been
    paid within six(6) month prior to the month of this confinement.

    Signature of Member Printed Name & Signature of Witness to Thumbmark

    If unable to write, affix Right thumbmark


    PART II - EMPLOYER'S CERTIFICATION (For employed members only)
    14. Registered Name of Employer

    Identification No. of Employer


    15. Address of Employer ( No., Street, Barangay/Municipality/City, Province, Zip Code )
    No., Street Barangay

    Municipality/City Province Zip Code

    16. CERTIFICATION of EMPLOYER: This is to certify that three(3) applicable monthly contributions were collected during the six(6) month period prior to the
    month of this confinement and that the data supplied by the member on Part I are true and conform with our available records.

    Signature Over Printed Name of Authorized Representative Date Signed Official Capacity

    cut here
    Member's Copy This portion should be completely filled up, detached by the hospital and given to member
    ACKNOWLEDGEMENT RECEIPT
    Name of Member : SSS/GSIS/MEC/PhilHealth No. :
    Name of Patient : Confinement Period :
    Name of Hospital : PhilHealth Forms Received by :
    Address of Hospital : Date :
    IMPORTANT

    1. For currently employed member, the original and properly accomplished Form 1 is sufficient. In case item no. 16
    ( Certification of Employer ) is not properly accomplished ( ex. separated from employment, but contribution is still
    qualified for the confinement period ) submit RF-1 and ME-5 and/or applicable receipts
    2. Beneficiary/Hospital representative to attach the following supporting document/s for:

    a) Individually paying ( voluntary, self-employed or OFW members), any of the following:

    Official Receipts of PhilHealth accredited collecting banks or PhilHealth Bank Receipts (PBR)
    Duly validated MI-5 ( Contributions Payment Return Form ) for individually paying members starting January 2000
    Official Receipts issued by PhilHealth ( for over the counter payments )

    b) SSS/GSIS Retirees, any of the following:

    Latest pension voucher


    Copy of bank account passbook ( with pages indicating name of pensioner and latest pension entry )
    Retirement Certificate issued by the GSIS/SSS

    c) AFP/PNP Retirees, any of the following:

    General or Special Orders


    Latest pension voucher
    Certification of 120 monthly Medicare/NHIP contributions from the GSIS or from previous employer
    Service record

    d) Retired Judges, any of the following:

    Certificate of retirement from the Office of the Court Administration (OCA)


    Certification of 120 monthly Medicare/NHIP contributions from the GSIS or from previous employer
    Service record

    e) SSS partial disability pensioners - certificate from SSS indicating coverage/period of pension

    f) Dependents of a, b, c, d and e - approved M1b or E1/E4 for SSS members or

    SPOUSE - copy of marriage contract


    CHILD - copy of birth or baptismal certificate
    Illegitimate/Legitimated child - birth certificate acknowledged by the father/mother or notarized affidavit of support
    Legally adopted child - legal adoption paper or notarized affidavit that child is legally adopted
    Step-child birth or baptismal certificate with copy of marriage contract or
    . .

    affidavit by the step-mother or step-father


    PARENT - affidavit of support ( original or Certified True Copy )

    g) OWWA member/dependent - Certified True Copy of Medicare Eligibility Certificate ( MEC )

    Legend:
    RF-1 - Quarterly Remittance Report form
    ME-5 - Contributions Payment Return form for employed sector
    MI-5 - Contributions Payment Return form for individually paying members
    M1b - Membership Data Record form for individually paying
    E1 - SSS Membership form for new member
    E4 - SSS Member's Data Ammendment form

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