Ph

Region : V
Division Office: SORSOGON
PIN
*LHIO CODE LAST NAME FIRST NAMEMIDDLE NAME EXT NAME SEX
(Member)

* To be filled out by the PRO/LHIO

** Indicate member or dependent

Data Privacy: The Department of Education recognize its responsibility under the Republic Act No. 10173 (A
 PhilHealth - DepEd Partnership for Konsulta Implementation
List of Beneficiaries

SCHOOL/OFFICE
DATE OF BIRTH
CONTACT NO. EMAIL ADDRESS ADDRESS
(yyyy-mm-dd) NAME
Barangay

public Act No. 10173 (Act), also known as the Data Privacy Act of 2012, with respect to the data they collect, record, or
 Annex A

OOL/OFFICE
KONSULTA PROVIDER
ADDRESS **TAG *MEMBER CATEGORY ID
(To be filled-out by PhilHealth)
Municipality/City Province

they collect, record, organize, update, use, consolidate or destruct from their personnel. The p
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