Scribd Logo
Upload

Welcome to Scribd!

  • 223 views

    E Konsulta Form

    Uploaded by

    Rogie Contridas Palaran
    This document contains a PhilHealth Konsulta Registration Form to be filled out by beneficiaries to register for PhilHealth's teleconsultation services. It requests the beneficiary's name, PhilHealth card number, contact details, and preferred teleconsultation facility. Once completed by the beneficiary and authorized personnel, it provides registration details and instructions for proper form completion.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content

    You might also like

    E Konsulta Form

    Uploaded by

    Rogie Contridas Palaran
    223 views2 pages
    This document contains a PhilHealth Konsulta Registration Form to be filled out by beneficiaries to register for PhilHealth's teleconsultation services. It requests the beneficiary's name, PhilHealth card number, contact details, and preferred teleconsultation facility. Once completed by the beneficiary and authorized personnel, it provides registration details and instructions for proper form completion.

    Original Description:

    Original Title

    eKonsultaForm

    Copyright

    © © All Rights Reserved

    Available Formats

    DOCX, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Report this Document
    This document contains a PhilHealth Konsulta Registration Form to be filled out by beneficiaries to register for PhilHealth's teleconsultation services. It requests the beneficiary's name, PhilHealth card number, contact details, and preferred teleconsultation facility. Once completed by the beneficiary and authorized personnel, it provides registration details and instructions for proper form completion.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    223 views2 pages

    E Konsulta Form

    Uploaded by

    Rogie Contridas Palaran
    This document contains a PhilHealth Konsulta Registration Form to be filled out by beneficiaries to register for PhilHealth's teleconsultation services. It requests the beneficiary's name, PhilHealth card number, contact details, and preferred teleconsultation facility. Once completed by the beneficiary and authorized personnel, it provides registration details and instructions for proper form completion.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    of 2

    PhilHealth Konsulta Registration Form PhilHealth Konsulta Registration Form PhilHealth Konsulta Registration Form

    To be filled-out by the Beneficiary To be filled-out by the Beneficiary To be filled-out by the Beneficiary


    Name: _____________________________________ Name: _____________________________________ Name: _____________________________________
    PIN: _______________________________________ PIN: _______________________________________ PIN: _______________________________________
    Member: ___ Dependent: ____ (please check) Member: ___ Dependent: ____ (please check) Member: ___ Dependent: ____ (please check)
    Contact No.: _______________________________ Contact No.: _______________________________ Contact No.: _______________________________
    Email Address (if applicable): __________________ Email Address (if applicable): __________________ Email Address (if applicable): __________________

    Preferred PhilHealth Konsulta Facility and Address Preferred PhilHealth Konsulta Facility and Address Preferred PhilHealth Konsulta Facility and Address
    (Municipality/Town/City/Province): (Municipality/Town/City/Province): (Municipality/Town/City/Province):
    1st Choice: OLUTANGA MUNICIPAL HOSPITAL______ 1st Choice: OLUTANGA MUNICIPAL HOSPITAL______ 1st Choice: OLUTANGA MUNICIPAL HOSPITAL______
    2nd Choice: __________________________________ 2nd Choice: __________________________________ 2nd Choice: __________________________________
    3rd Choice: __________________________________ 3rd Choice: __________________________________ 3rd Choice: __________________________________

    _______________________________ _______________________________ _______________________________


    Signature over Printed Name Signature over Printed Name Signature over Printed Name
    PhilHealth’s Copy PhilHealth’s Copy PhilHealth’s Copy
    ------------------------------------------------------------------------- ------------------------------------------------------------------------- -------------------------------------------------------------------------
    PhilHealth Konsulta Registration Confirmation PhilHealth Konsulta Registration Confirmation PhilHealth Konsulta Registration Confirmation
    SlipTo be filled-out by the Authorized SlipTo be filled-out by the Authorized SlipTo be filled-out by the Authorized
    personnel personnel personnel
    Registration No.: ________________________________ Registration No.: ________________________________ Registration No.: ________________________________
    Date Registered: ________________________________ Date Registered: ________________________________ Date Registered: ________________________________
    Name: ________________________________________ Name: ________________________________________ Name: ________________________________________
    PIN: __________________________________________ PIN: __________________________________________ PIN: __________________________________________
    PhilHealth Konsulta Facility: OLUTANGA MUNICIPAL HOSPITAL PhilHealth Konsulta Facility: OLUTANGA MUNICIPAL HOSPITAL PhilHealth Konsulta Facility: OLUTANGA MUNICIPAL HOSPITAL
    PhilHealth Konsulta Facility Address: Bateria, Olutanga, Zamboanga Sibugay PhilHealth Konsulta Facility Address: Bateria, Olutanga, Zamboanga Sibugay PhilHealth Konsulta Facility Address: Bateria, Olutanga, Zamboanga Sibugay

    ____________________________________ ____________________________________ ____________________________________


    Signature over Printed Name of Authorized Personnel Signature over Printed Name of Authorized Personnel Signature over Printed Name of Authorized Personnel

    Beneficiary’s Copy Beneficiary’s Copy Beneficiary’s Copy


    Instructions: Instructions: Instructions:
    1. All information should be written in UPPER CASE/CAPITAL 1. All information should be written in UPPER CASE/CAPITAL 1. All information should be written in UPPER
    LETTERS. LETTERS. CASE/CAPITAL LETTERS.
    2. All fields are mandatory. 2. All fields are mandatory. 2. All fields are mandatory.
    3. If the beneficiary is dependent, use the dependent PIN. 3. If the beneficiary is dependent, use the dependent PIN.
    3. If the beneficiary is dependent, use the dependent PIN.
    4. If the beneficiary is below 21 years old, the signatory should 4. If the beneficiary is below 21 years old, the signatory
    4. If the beneficiary is below 21 years old, the signatory
    be the parent/guardian. should be the parent/guardian.
    should be the parent/guardian.

    You might also like