Philippine Government Forms All in One Location
PhilHealth application form for dialysis database
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Draft Version 1.0 : February 22, 2016
PHILHEALTH DIALYSIS DATABASE
I would like to register under the PhilHealth Dialysis Database. I understand that the
following information will be used by PhilHealth for my claims reimbursement. Also,
I am giving my consent to access on my pertinent clinical information.
1. PhilHealth Identification Number (PIN)
2. Name of CKD Patient
3. Currently, I am a
4. Date of Birth
(example: DELA CRUZ JUAN JR SIPAG)
Name Extension (JR/SR/III)
6. Civil Status:
7. Mailing Address
Unit/ Room No., Floor
8. Email Address
9. Mobile Number
11. Is the patient enrolled under the Z benefits?
PD First Policy
12. Previous availment under All Case Rates?
(month & year)
13. I started dialysis on
14. For HD: Type of dialyzer
15. For PD: Current PD system
I certify that the herein information given are true and correct.
18. PDD Registration No.
19. Registered by
Name of Health Care Institution
21. Registration Date
20. Accreditation No.