Control No:

Registration
date:
Request Type1:  New  Transfer
 Update  Deactivate
HCI / RHU INFORMATION
Name of Facility PEN
Address of Facility

Authorized Representative Contact No.

Designation of Representative Email Address

ACCREDITATION INFORMATION
PMCC Number
Accreditation Number / s Name of Facility (as appearing in the Accreditation Certificate)
(to be filled-up by PhilHealth)

ENGAGEMENT INFORMATION
Name of Service Provider PEN
Address of Service Provider
Authorized Representative Contact No.
Designation of Representative Email Address
SYSTEM INFORMATION
Name of System System Version2
Type of System  In-house  Outsourced Date Implemeted3
Software Certificate No.4 Date of Certificate Issuance5
Transmission Options6  HITP  HCI  HIS
 EMR  PHIC
COMPLIANCE TO eCLAIMS GUIDELINES
The UNDERSIGNED shall ensure compliance to the eClaims guidelines:
1. The system implemented in the HCI shall strictly conform to the existing laws, policies and guidelines implemented by regulatory bodies and
registering offices such as but not limited to the Data Privacy Act of 2012;
2. The HCI certifies that all data that shall be transmitted to PhilHealth is complete, accurate and true;
3. The HCI shall be solely responsible for the protection of their equipment and backup of data.
4. The HCI shall not hold PhilHealth liable for any loss or damages in connection with the use/distribution of PhilHealth internally developed
systems and web services;
5. All requests for assistance shall be emailed to [email protected];

_________________________________________ __________________
Name and Signature of Authorized Representative Date Signed
PHILHEALTH PORTION
Received by Date Received
SDURF No Enrolled by Date Enrolled

ACCOUNT INFORMATION SLIP CONTROL NO.

Account Name Password

Test Environment Accessibility Date
Live Environment Accessibility Date
GUIDELINES IN FILLING OUT THE FORM
1. Indicate the type of request. For New requests, ensure that the applications that will be used has already been validated by PhilHealth. For new and transfer requests, attach a copy of the
current agreement with the service provider. For changes in the system version, tick the Update checkbox.
2. The implemented version should be the one duly validated by PhilHealth. A separate Software Compliance Test and Certificate shall be issued for every change in the system.
3. The Date for Implementation shall mean the date the system will be used to transmit the claims electronically to PhilHealth.
4. Indicate the Software Certificate No. appearing in the PhilHealth issued Software Compliance Certificate.
5. Indicate whether the system is developed in-house or outsourced. Outsourced shall mean either solutions provided by PhilHealth or a Service Provider.
6. In the Transmission Options please see below:
a. HITP – For HCIs, select if you will use the services of the accredited Health Information Technology Providers.
b. EMR – For RHUs, select if you will be using the services of an EMR provider.
c. PHIC – Check if you will be using either the PHICS or the S-Claims
d. HCI – Check if you will be using an internally developed application.
e. HIS – Check if you are using an outsourced application not developed by the HITP or identified EMR provider.
7. The account information or the connection settings shall be sent to the email address of the authorized representative.
 ACK REQUEST NO

ACCOUNT & CIPHER KEY ENGAGEMENT NO

REQUEST FORM DATE

I. HEALTH CARE INSTITUTION (HCI) INFORMATION

Accreditation
No.
Name of Facility
Complete
Address
Email Address
Contact No.

II. ENGAGEMENT INFORMATION

Name of Service
Provider
Software Certificate
No.

CIPHER KEY COMPLIANCE AGREEMENT

The UNDERSIGNED agrees/certifies to adhere to the following:

1. To use my account and cipher key information conscientiously and not to share and
allow anyone to use this information in compliance to the Data Privacy Act.
2. To report any possible security problems / breaches immediately to PhilHealth for
replacement of the HCI cipher key.
3. The undersigned is authorized to receive the Cipher Key in behalf of the Health Care
Institution and that the cipher key will be used only for its intended purpose such as
to encrypt the electronic medical data prior to submission to PhilHealth.
4. I am aware that PhilHealth will not be held liable / accountable for the loss and
misuse of the cipher key and any other information breaches that may arise from
this incident.
5. All the above information is true and correct to the best of my knowledge and belief.

_________________________________________________________________________
Name and Signature of HCI Head or Authorized Representative

________________________
Date signed