Republic ofthe Philipines PHILIPPINE HEALTH INSURANCE CORPORATION ‘Ctystate Cenize 709 Shaw Boulevard. Pasig Cty alee (02) 4817442 + Trnklne (02 441 7444 itheorph PhilHealth This frm may berepocucedand NOT FORA CF-1 (Claim Form) Revised Sep IMPORTANT REMINDERS: er vith ether supporting ac alas hemes Storm atenecessry Ci id be fed with 6 day om 0 cays rom ds storm at of lecharge fezcnares 1.PhilHealth Identification Number (PIN) of Member: 2. Name of Member: asta - Fest Name Name fitension ‘month year 5.Sex: Female Unit/Room Nol - Building Name Tot/BW/House/BidgNo ‘street aay aap pane oy ar 6.Contact Information: Landline No, (Area Code + Tel, No} - Wobile No ~ Email Address: 7-Patientis the member? [_] yexrocesoFarth [] No Pro Ere ucla eee ener 1 PhilHealth Identification Number (PIN) of Dependent: [T |-[ 111111111] 2.Name of Patient: 3.Date of Birt! LastName Fistiame a on yea 4.Relationship to Member: [_]chis: [_] Pant 8.8ex: [] viele [_] renate eked Under the penalty of law, lattest that the information | provided in this Form are true and accurate to the best of my knowledge. puvigh tumbrare MemberRepesrtatve shipotthe © ans Co , O: 1.PhilHealth Employer Number (PEN): 3. Business Name: ‘4. CERTIFICATION OF EMPLOYER: Thiet certify thot the required 3/6 monthly premium contributions plus at east 6 months contbution preceding the 3 months qualifying contributions within 12 ‘month period prior tthe fist dey o confinement (suficient regulary) have been regularly remitted to PhiHealth Moreover, the information supplied bythe member or hishher representative on Part are consistent wth our available records” CLOICLH Date Sig