Philippine Health Insurance Corporation

ADVISORY
No. 2022- 0016
Phil Health
Your Partner in Health
UNI V ERSAL HEALTH CARE
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Updating of Forms for Selected Z Benefit Packages

This is to inform all contracted healthcare providers (HCP) for the Z Benefits for prostate cancer, kidney transplantation and PD First
of the following updated forms:

Z Benefits Updated Annexes

Z Benefits for Prostate Cancer Annex A: Pre-authorization Checklist and Request
Z Benefits for Kidney Transplantation Annex C1: Checklist of Mandatory and Other Services
PD First Z Benefits Annex F: PD First Passport

Beginning July 1, 2022, contracted HCPs shall submit the updated forms along with other requirements when filing claims for the
respective Z Benefits packages.

PhiiHealth will implement a grace period until June 30,2022, to allow contracted HCPs to use the old forms. During this period, all
PhiiHealth Regional Offices (PROs) shall process claims for reimbursement using the old forms.

The updated forms may be downloaded from the PhiiHealth website at www.philhealth.gov.ph/downloads/

Further inquiries may be coursed through the Phil Health Callback Channel at Callback Channel: 0917-898- 7442 (PHIC) or any of
the PhiiHealth Regional and Local Health Insurance Offices.

(Sgd.) ATTY. DANTE A. GIERRAN, CPA

President and Chief Executive Officer

Annex

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MANDATORY SERVICES OTHER SERVICES

lmmunosupprcS$ionoptions: PRE-TRANSPLANT EVALUATION FORM FOR KIDNEY TRANSPLANT RECIPIENT
(Tick ~ ny one of the following) Attachmcntlo Tranchcl*

Plcascanswerall qucstionsoompletelyandaccurately.Tick appropriatebo,.-es.

HEALTI-l. CARE PROVIDER (HCP)
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D \Vtthout co-p•yment 0 With co-payment

Age _ Se>: 0 Male IJ Female . Civil S~rus: 0 Single 0 M~nied 0 Widow '0 Scparoted

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D Methylprednisolone500mg1Vpcrdayfor
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