Claim Forms

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:

Gov't. Sector

Private Sector

Indigent

Individually paying: Retiree/Pensioner:

Self-employed

OFW

SSS

Military

GSIS

Others

OWWA

Judiciary

Identification No. 2. Name of Member Last Name

3. Date of Birth m m d d y y y y

First Name

4. Civil Status

Middle Name

6. Address of Member No., Street

Barangay

Municipality/City

Province

7. Name of Spouse Last Name

5. Sex

Single

Separated

Married

Widow/er

Male Female

Zip Code

First Name

Middle Name Not Applicable 8. Name of Patient Last Name

Patient is the Member

9. Date of Birth m m d d y y y y

First Name 10. Age

11. Sex

Middle Name

Male 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 birth or baptismal certificate with copy of marriage contract or Step-child 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 ME-5 MI-5 M1b E1 E4

-

Quarterly Remittance Report form Contributions Payment Return form for employed sector Contributions Payment Return form for individually paying members Membership Data Record form for individually paying SSS Membership form for new member SSS Member's Data Ammendment form

This form may be reproduced and is NOT FOR SALE

PHILHEALTH CLAIM FORM 2 Revised May 2000

HEALTH CARE PROVIDER'S CERTIFICATION

Note: This form together with Claim Form 1 should be filed with PhilHealth within 60 calendar days from date of discharge.

PART I - HOSPITAL DATA AND CHARGES ( Hospital to Fill in All Items ) 1. PhilHealth Accreditation No.

2. Accreditation Category

Primary

Secondary

Tertiary

Ambulatory

3. Name of Hospital/Ambulatory Clinic 4. Address of Hospital/Ambulatory Clinic No., Street

Barangay

Municipality/City

Province

5. Name of Member and Identification Last Name

Zip Code

First Name

Middle Name

Identification No.

6. Address of Member No., Street

Barangay

Municipality/City

Province

7. Name of Patient Last Name

Zip Code

8. Age

10. Admission Diagnosis

9. Sex

First Name

M

Middle Name

F

11. Confinement Period m m d d y y y y a. Date Admitted b. Time Admitted

:

AM/PM

12. Hospital/Ambulatory Services

m m d d y y y y c. Date Discharged d. Time Discharged

:

AM/PM AM/PM

ACTUAL HOSPITAL/

e. Claimed No.of Days m m d d y y y y f. Date of Death (If Applicable)

BENEFIT CLAIM PATIENT HOSPITAL

REDUCTION CODE a. Room and Board b. Drugs and Medicines ( Part III for details ) c. X-ray/Lab. Test/Others ( Part IV for details ) d. Operating Room Fee e. Medicines bought & laboratory performed outside hospital during confinement period TOTAL 13. CERTIFICATION of HOSPITAL/AMBULATORY CLINIC: I certify that the services rendered are duly recorded in the patient's chart and that the information given in this form are true and correct. AMBULATORY CHARGES

Signature Over Printed Name of Authorized Representative

Date Signed

Official Capacity

PART II - PROFESSIONAL DATA AND CHARGES ( Doctor/s to Fill in Respective Portions ) 14. Complete Final Diagnosis

FOR PHILHEALTH USE

Relative Unit Value 15. Case Type

Ordinary

Intensive

Catastrophic

16. Name of Attending Physician 17.PHIC Accreditation No. 19. Services Performed

-

18. BIR/TIN No. 20.

Actual

P

P

21. Name of Surgeon

P

Reduction Code

Signature & Date Signed

22.PHIC Accreditation No.

23. BIR/TIN No.

24. Services Performed

25.

-

Professional Charges

P

26. Name of Anesthesiologist

-

Benefit Claim Surgeon Patient

Actual

P

P Reduction Code

Signature&&Date DateSigned Signed Signature

27.PHIC Accreditation No.

28. BIR/TIN No.

29. Services Performed

30.

-

-

Benefit Claim Physician Patient

Actual

Professional Charges

P

Reduction Code

Benefit Claim Physician Patient

Professional Charges

Date of Operation

Illness Code

Signature & Date Signed

P

P

NOTE:Anyone who supplies false or incorrect information requested by this or a related form or commits misrepresentation shall be subject to criminal,civil or administrative prosecution under the law.All data required on this form are necessary for adjudication of the claim.PhilHealth will not adjudicate any claim where forms are not properly or completely accomplished.

PART III - DRUGS AND MEDICINES Preparation Unit Price

(cap/sy/inj/tab with

Generic name

Brand

ml/mg/gm content)

Qty.

Actual Charges

Benefit Claim Hospital Patient

Actual Charges

Benefit Claim Hospital Patient

1. 2. 3. 4. 5. 6. 7. 8. 9. 10 11. 12. 13. 14. 15. TOTAL NOTE: Official Receipts for drugs and medicines purchased by patient must be attached to this claim.

PART IV - X-RAY, LABORATORIES AND OTHERS Unit Price

Qty.

Particulars

A. X-ray/Lab. 1. 2. 3. 4. 5. B. Supplies 1. 2. 3. 4. 5. C. Others 1. 2. 3. 4. 5. TOTAL NOTE: Official Receipts for laboratory procedures performed outside the hospital during this confinement period must be attached to this claim.

PART V - CERTIFICATION of PATIENT/MEMBER I hereby certify that: The amount of P

was deducted from the hospital charges.

The amount of P

was deducted from the professional fee charges.

The amount of P

was paid for medicines/lab. acquired outside the hospital during this confinement

( Official Receipts attached ). No deduction was made from the hospital charges. No deduction was made from the professional fee charges.

Date

Signature Over Printed Name of Patient/Member

This form may be reproduced and is NOT FOR SALE

PHILHEALTH CLAIM FORM 3 Revised May 2000

PATIENT'S CLINICAL RECORD

Note: This form should be filed with PhilHealth within 60 calendar days from date of discharge.

Case No.: Admission: m m d d y y y y Date:

AM/PM Time:

:

Accreditation No.:

Name of Hospital/Ambulatory Clinic:

Address of Hospital/Ambulatory Clinic: No., Street

Barangay

Municipality/City

Province

Zip Code

PATIENT'S CLINICAL RECORD 1. Patient Name Last Name

2. Age

3. Sex

Male Female

First Name

4.

Middle Name Printed Name & Signature of Admitting Officer 5. Admitting Diagnosis:

6. Chief Complaint:

7. Reason for Admission:

8. Brief History of Present Illness/OB History:

9. Physical Examination ( Pertinent Findings per System ) General Survey: Vital Signs: BP: HEENT: Chest/Lungs: CVS: Abdomen: GU ( IE ): Skin/Extremities: Neuro Examination:

HR:

RR:

Temperature:

10. Course in the Wards:

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

12. Surgical Operation:

AM/PM

m m d d y y y y Date:

Time:

Printed Name & Signature of Surgeon

:

Printed Name & Signature of Anesthesiologist

Type of Anesthesia: 13. Discharge: m m d d y y y y a. Date:

AM/PM b. Time:

:

c. Final Diagnosis:

d. Condition on Discharge:

e. Signature of Attending Physician: 14. Signature or Right Thumbmark of patient or his/her representative:

Printed Name & Signature of Patient or his/her Representative

Right thumbmark (In case patient and representative could not write)

Printed Name & Signature of Witness to Thumbmark

This form may be reproduced and is NOT FOR SALE

PHILHEALTH CLAIM FORM 4

MATERNITY CARE PACKAGE

April 2003 NOTE: THIS FORM TOGETHER WITH CLAIM FORM 1 SHOULD BE FILED WITH PHILHEALTH WITHIN 60 CALENDAR DAYS FROM DATE OF DISCHARGE.

PART I - FACILITY DATA AND CHARGES ( Facility to Fill in All Items ) 1. PhilHealth Accreditation No.

2. Accreditation Category

Secondary

Primary

Tertiary

Non-Hospital Facilities (Lying-in clinics,Midwife-managed clinics, Birthing Homes,Ambulatory Surgical Clinics) 3. Name of Facility 4. Address of Facility No., Street

Barangay

Municipality/City

Province

5. Name of Member and Identification Last Name

Zip Code

First Name

Middle Name

PhilHealth Identification No.

6. Address of Member No., Street

Barangay

Municipality/City

Province

7. Name of Patient Last Name

Zip Code

8. Age

9. Admission Diagnosis

First Name Middle Name 10. Confinement Period a. Date Admitted

m m d d y y y y

11. Facility Services

m m d d y y y y b. Date Discharged

c. Total No.of Days d. Date of Death (If Applicable)

ACTUAL FACILITY

BENEFIT CLAIM FACILITY PATIENT

CHARGES

m m d d y y y y

REDUCTION CODE

TOTAL Medicines & Supplies bought & laboratory performed outside facility during confinement period 12. CERTIFICATION of FACILITY: I certify that the services rendered are duly recorded in the patient's chart and that the information given in this form are true and correct.

Signature Over Printed Name of Authorized Representative

Date Signed

Official Capacity

PART II - PROFESSIONAL DATA AND CHARGES (Provider/s to Fill in Respective Portions ) 13. Complete Final Diagnosis

14. ICD-10 Code:

FOR PHILHEALTH USE

RVS Code

Signature & Date Signed

15. Name of Provider

16.PHIC Accreditation No.

17. BIR/TIN No.

18. Services Performed

19. Actual Professional Charges

P

-

Illness Code

Reduction Code

Benefit Claim

Provider

P

Patient

P

NOTE: ANYONE WHO SUPPLIES FALSE OR INCORRECT INFORMATION REQUESTED BY THIS OR A RELATED FORM OR COMMITS MISREPRESENTATION SHALL BE SUBJECT TO CRIMINAL, CIVIL OR ADMINISTRATIVE PROSECUTION UNDER THE LAW. ALL DATA REQUIRED ON THIS FORM ARE NECESSARY FOR ADJUDICATION OF THE CLAIM. PHILHEALTH WILL NOT ADJUDICATE ANY CLAIM WHERE FORMS ARE NOT PROPERLY OR COMPLETELY ACCOMPLISHED.

PHILHEALTH

MATERNITY CARE PACKAGE

CLAIM FORM 4A April 2003

NOTE: THIS FORM TOGETHER WITH CLAIM FORM 4 SHOULD BE FILED WITH PHILHEALTH WITHIN 60 CALENDAR DAYS FROM DATE OF DISCHARGE.

Name of Physician/Midwife: Name of Facility: Address of Facility: Name of Patient:

PART I - PRENATAL INITIAL PRENATAL CONSULTATION (date: ___/___/___) A. Clinical History and Physical Examination 1. Vital signs are normal 2. Menstrual History

LMP : ____________

4. Obstetric History

Menarche: ____________

G______ P______ ( ______ ,______ ,______ ,______ )

5. Ascertain 1st Pregnancy was Low-Risk 6. Obstetric risk factors a. Multiple pregnancy

f. History of stillbirth

b. Ovarian cyst

g. History of pre-eclampsia

c. Myoma uteri

h. History of eclampsia

d. Placenta previa

i. Premature contraction

e. History of 3 miscarriages

7. Medical/Surgical Risk Factors a. Hypertension

g. Epilepsy

b. heart disease

h. Renal disease

c. Diabetes

I. Bleeding disorders

d. Thyroid disorders

j. History of previous cesarean section

e. Obesity

k. History of uterine myomectomy

f. Moderate to severe asthma

8. Determine pertinent abdominal examinations a. Abdomen normoactive bowel sound

fundic ht= _______________

non-tender

estimated fetal wt: _________

active fetal movements

FHT= __________

b. Speculum Exam

Leopold's Maneuver L1: ________ L3: _________ L2: ________ L4: _________ presentation: __________________________

c. Internal Exam

parous vagina

uterus enlarged to AOG

cervix smooth, closed

adnexal masses

9. Give complete diagnosis: _________________________________________________________________________ B. Write Delivery Plan indicating: 1. Orientation to LRMC Package/Availment of Benefits 2. Schedule of prenatal examinations Date: ___/___/___

3. Expected date and venue of delivery Place: ___________________

FOLLOW-UP PRENATAL CONSULTATION (date: ___/___/___) Visit No. Date of visit A. Determine AOG in weeks B. Obtain vital signs

2nd

3rd

4th

5th

6th

7th

8th

9th

a. Wt b. HR c. RR d. BP e. T

PART II - NORMAL BIRTH (date:__/__/__) DONE A. Perform complete Physical Examination (VS) 1. Determine AOG

AOG: ___________

2. Obtain Vital Signs

HR: _____

LMP: ___________

RR: _____

BP: _____ T: ____

3. Perform pertinent physical examination a. HEENT anicteric sclerae pink palpebral conjunctiva

b. Heart/Lungs

(+) (+)

REMARKS _______________

(-) (-)

clear breath sounds sinus rhythm

c. Skin/Extremities

(+) (+)

REMARKS _______________

(-) (-)

full pulses bipedal edema

(+) (+)

(-) (-)

REMARKS _______________

10th

11th

12th

4. Determine pertinent abdominal examinations regular uterine contractions (+) (-) (+) (-) bloody show (+) (-) active fetal movements

FHT= __________ fundic ht= _______________ estimated fetal wt: _________

5. Perform IE BOW:__________________ Cervical Effacement: _______________ Presentation: ____________ Cervical dilatation: ___________________ Station: ________________ B. Ascertain that patient is in true active labor

Time of start of labor:

C. Admit and obtain informed consent

Time of Admission:

D. Monitor course of labor, accomplish partogram E. Prepare Delivery Room F. Attend to Delivery of Baby

Time of delivery of newborn:

G. Get APGAR score of Newborn

APGAR :

H. Routine Newborn Care I. Perform Delivery of Placenta

Time of delivery of placenta:

J. Check if placenta is complete K. Ensure good uterine contraction L. Inspect for perineal and vaginal lacerations M. Explain to patient the procedure of perineal repair N. Suture perineal laceration under Local Anesthesia O. Check repair and ensure hemostasis P. Transfer patient to recovery area Q. Monitor during Immediate Postpartum Period

BP: ____ HR: ____RR: ____T: ____

R. Discharge Clearance (D/C IE)

Vagina: Cervix: Uterus:

S. Give Complete Diagnosis OB Score : G ____ P ____ ( ____ , ____ , ____ , ____ )

Maternal Outcome:

_________________ ,

_________________ ,

Pregnancy Uterine

Birth Outcome:

____________ , Live

_________________ ,

AOG by LMP

____________ , Sex

____________ , Birthweight

Manner of Delivery

________________ Presentation

____________ APGAR Score

T. Accomplish documents for PHIC Reimbursement U. Schedule Postpartum and Newborn Care follow-up

Date: ______________________

consult - 1 week after delivery V. Discharge Patient

Date and Time of Discharge: ______________________

PHILHEALTH

MATERNITY CARE PACKAGE

CLAIM FORM 4B April 2003

NOTE: THIS FORM TOGETHER WITH CLAIM FORM 4 SHOULD BE FILED WITH PHILHEALTH WITHIN 90 CALENDAR DAYS FROM DATE OF DISCHARGE.

Name of Physician/Midwife: Name of Facility: Address of Facility: Name of Patient:

POST-PARTUM CARE (date:__/__/__) DONE

REMARKS

A. Check perineal wound healing B. Check for signs of Maternal Postpartum complications C. Check for signs of Newborn complications D. Counselling and Education 1. Newborn Care 2. Breastfeeding and Nutrition 3. Newborn Immunization 4. Family Planning E. Provide family planning service to patient if requested F. Refer to Partner Physician for Voluntary Surgical Sterilization, if requested by patient G. Schedule postpartum visit 6 weeks postpartum

PHILHEALTH

TB-DOTS PACKAGE CLAIM FORM 5

March 2003

NOTE: THIS FORM TOGETHER WITH CLAIM FORM 1 SHOULD BE FILED WITH PHILHEALTH WITHIN 60 CALENDAR DAYS FROM DATE OF COMPLETION OF TREATMENT

1. PhilHealth Accreditation No.

2. Name of Hospital/DOTS Center

3. Address of Hospital/DOTS Center No., Street

Barangay

Municipality/City

Province

4. Name of Member Last Name

Zip Code

PIN

First Name Middle Name

5. Address of Member No., Street

Barangay

Municipality/City

Province

Zip Code

6. Name of Patient Last Name

7. Age

First Name

8. Sex

9. Date of Registration Enrollment: Date of Completion:

M

Middle Name

F

intensive phase

date of death

maintenance

10. Diagnosis and ICD-10 Code:

11. CLASSIFICATION OF TB:

12. CATEGORY (tick box):

Pulmonary

I. 6-SCC (2HRZE/4HR)

Extra-Pulmonary site: _______________

TYPE OF PATIENT:

1.Relapse

2.Failure

1. Smear (+)

3. Return After Default (RAD)

4. Other (smear +)

2. Seriously ill

New

Return After Default (RAD)

Relapse

Failure

Trans. In

Other

II. 8-CC (2HRZES/5HRE)

New Case

2.1. Smear (-): MA or FA Radiographic lesion 2.2. Extra-pulmonary

III. 6-SCC (2HRZ/4HR) New Case 1. Smear (-): Minimal 2. Extra-pulmonary not seriously ill

13.CERTIFICATION of HOSPITAL/DOTS CENTER: I certify that the services rendered are duly recorded in the patient's chart and that the information in this form are true and correct.

Signature Over Printed Name of Authorized Representative

Date Signed

Official Capacity