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    PhilHealth Circular No. 0035, s.2013 Annex11 PhilHealthClaimForm3 Frontpage (RevisedNovember2013)

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    Chrysanthus Herrera
    This 3 sentence summary provides the key details from the document: The document appears to be a claim form for a Philippine Health Insurance Corporation (PhilHealth) member, as it requests information such as the patient's name, chief complaint, admission and discharge dates and times, physical examination findings, course in the hospital, diagnostic tests, and disposition at discharge. The form indicates it should not be sold and was last revised in November 2013. It collects clinical and billing information necessary to process an insurance claim for services received as an inpatient.

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    Download as PDF, TXT or read online from Scribd

    PhilHealth Circular No. 0035, s.2013 Annex11 PhilHealthClaimForm3 Frontpage (RevisedNovember2013)

    Uploaded by

    Chrysanthus Herrera
    90 views2 pages
    This 3 sentence summary provides the key details from the document: The document appears to be a claim form for a Philippine Health Insurance Corporation (PhilHealth) member, as it requests information such as the patient's name, chief complaint, admission and discharge dates and times, physical examination findings, course in the hospital, diagnostic tests, and disposition at discharge. The form indicates it should not be sold and was last revised in November 2013. It collects clinical and billing information necessary to process an insurance claim for services received as an inpatient.

    Original Description:

    PhilHealth Circular No. 0035, s.2013 Annex 11

    Original Title

    PhilHealth Circular No. 0035, s.2013 Annex11 PhilHealthClaimForm3 Frontpage(RevisedNovember2013)

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    This 3 sentence summary provides the key details from the document: The document appears to be a claim form for a Philippine Health Insurance Corporation (PhilHealth) member, as it requests information such as the patient's name, chief complaint, admission and discharge dates and times, physical examination findings, course in the hospital, diagnostic tests, and disposition at discharge. The form indicates it should not be sold and was last revised in November 2013. It collects clinical and billing information necessary to process an insurance claim for services received as an inpatient.

    Copyright:

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

    PhilHealth Circular No. 0035, s.2013 Annex11 PhilHealthClaimForm3 Frontpage (RevisedNovember2013)

    Uploaded by

    Chrysanthus Herrera
    This 3 sentence summary provides the key details from the document: The document appears to be a claim form for a Philippine Health Insurance Corporation (PhilHealth) member, as it requests information such as the patient's name, chief complaint, admission and discharge dates and times, physical examination findings, course in the hospital, diagnostic tests, and disposition at discharge. The form indicates it should not be sold and was last revised in November 2013. It collects clinical and billing information necessary to process an insurance claim for services received as an inpatient.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    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

    CF3
    (Claim Form)
    revised November 2013

    PART I - PATIENT'S CLINICAL RECORD


    1. PhilHealth Accreditation No. (PAN) - Institutional Health Care Provider: 2. Name of Patient 3. Chief Complaint / Reason for Admission:
    First Name, Middle Name (example: Dela Cruz, Juan Jr., Sipag)

    Last Name,

    4. Date Admitted:
    Month Day Year

    Time Admitted:
    hh-mm

    AM hh-mm AM

    PM

    5. Date Discharged:
    Month Day Year

    Time Discharged:
    hh-mm

    hh-mm

    PM

    6. Brief History of Present Illness / OB History:

    7. Physical Examination ( Pertinent Findings per System ) General Survey: Vital Signs HEENT Chest/Lungs CVS
    :

    BP :

    CR:

    RR:

    Temperature:

    Abdomen GU ( IE ) Skin/Extremities Neuro Examination

    8. Course in the Wards (attach additional sheets if necessary):

    9. Pertinent Laboratory and Diagnostic Findings: ( CBC, Urinalysis, Fecalysis, X-ray, Biopsy, etc. )

    10. Disposition on Discharge:

    Improved

    Transferred

    HAMA

    Absconded

    Expired

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