PHILHEALTH ONLINE ACCESS FORM Series No.

Date
Revised POA Form No. 001, August 2012

Name of Employer Philhealth Employer Number (PEN)

Business Address Philippine Standard and Division Code Station Code

Geographic Coding (PSGC)

Name & Signature of Head of Position Email Address Telephone No./Mobile No.
Office

Name of Philhealth Employer’s Position of PEER Email Address Mobile No.

Engagement Representative (PEER)

PEER Company/Agency ID No. Telephone No.

To be filled-out by Philhealth

Registration Date Regional/Branch Office LHIO Orientation

Processed Date Processed By System to be accessed Role Assigned

PHILHEALTH ONLINE ACCESS FORM Series No. Date

Revised POA Form No. 001, August 2012

Name of Employer Philhealth Employer Number (PEN)

Business Address Philippine Standard and Division Code Station Code

Geographic Coding (PSGC)

Name & Signature of Head of Position Email Address Telephone No./Mobile No.
Office

Name of Philhealth Employer’s Position of PEER Email Address Mobile No.

Engagement Representative (PEER)

PEER Company/Agency ID No. Telephone No.

To be filled-out by Philhealth

Registration Date Regional/Branch Office LHIO Orientation

Processed Date Processed By System to be accessed Role Assigned