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  • AnnexA-POAF v102022

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    Jane myla matoto
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    This document is a registration form for PhilHealth Online Access that collects information about an accredited institutional health care provider or third party partner. It requests the name and address of the institution, contact information and digital signatures of the user and approvers. PhilHealth will then process the application, creating login credentials and confirming the registration with the institution.

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    AnnexA-POAF_v102022

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    This document is a registration form for PhilHealth Online Access that collects information about an accredited institutional health care provider or third party partner. It requests the name and address of the institution, contact information and digital signatures of the user and approvers. PhilHealth will then process the application, creating login credentials and confirming the registration with the institution.

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    © All Rights Reserved
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    Download as pdf or txt
    18 views1 page

    AnnexA-POAF v102022

    Uploaded by

    Jane myla matoto
    This document is a registration form for PhilHealth Online Access that collects information about an accredited institutional health care provider or third party partner. It requests the name and address of the institution, contact information and digital signatures of the user and approvers. PhilHealth will then process the application, creating login credentials and confirming the registration with the institution.

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    © All Rights Reserved
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    ANNEX A

    Registration Date
    PHILHEALTH ONLINE ACCESS FORM NO.
    (POAF) Form No. 002

    Name of Accredited Institutional Health Care Provider / Third Party Partner PhilHealth Accreditation Number

    Business Address

    User Profile
    Complete Name Signature

    Position Email address Mobile No.

    Approved by: Date Signed

    To be filled-out by PhilHealth
    Installation Date Regional / Branch Office Email address

    Username Password

    Processed by Signature Date Processed

    Approved by Signature Date Signed

    Institutional Confirmation
    Confirmed by: Medical Director/Administrator/Authorized Representative of Date Confirmed
    Third Party Partner

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