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CSF Claim Signature Form
PhilHeath form for claim signature
Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: CSF
(Claim SIgnature
Form)
IMPORTANT REMINDERS:
PLEASE WRITE IN CAPITAL LETTERS AND CHECK THE APPROPRIATE BOXES.
Series #
All information required in this form are necessary and claim forms with incomplete information shall not be processed.
FALSE / INCORRECT INFORMATION OR MISREPRESENTATION SHALL BE SUBJECT TO CRIMINAL, CIVIL OR ADMINISTRATIVE LIABILITIES.
PART I - MEMBER AND PATIENT INFORMATION AND CERTIFICATION
1. PhilHealth Identification Number (PIN) of Member:
2. Name of Member:
Last Name
First Name
Middle Name
( example: Dela Cruz, Juan Jr., Sipag)
3. Member Date of
Birth:
(month-day-year)
4. PhilHealth Identification Number (PIN) of Dependent:
5. Name of Patient:
Last Name
6. Relationship to Member:
First Name
Middle Name
7. Confinement Period
a. Date Admitted:
Child
( example: Dela Cruz, Juan Jr., Sipag)
c. Date Discharged:
Parent
Spouse
8. Patient Date of Birth:
(month-day-year)
(month-day-year)
(month-day-year)
9. CERTIFICATION OF MEMBER:
Under the penalty of law, I attest that the information I provided in this Form are true and accurate to the best of my knowledge.
Signature Over Printed Name of Member
Signature Over Printed Name of Member's Representative
Date Signed (month-day-year)
If member/ representative is unable to write, put right
thumbmark. Member/ representative should be assisted
by an HCI representative. Check the appropriate box:
Member
Date Signed (month-day-year)
Relationship of the
representative to the member:
Reason for signing on
behalf of the member:
Representative
Spouse
Child
Sibling
Others, specify ____________
Parent
Member is incapacitated
Other reasons______________
PART II - EMPLOYER'S CERTIFICATION (for employed members only)
1.PhilHealth Employer No. (PEN):
2. Contact No.:
3. Business Name:
Business Name of Employer
4. CERTIFICATION OF EMPLOYER:
This is to certify that all monthly premium contributions for and in behalf of the member, while employed in this company, including the
applicable three (3) monthly premium contributions within the past six (6) months period prior to the first day of this confinement, have been
deducted/collected and remitted to PhilHealth, and that the information supplied by the member or his/her representative on Part I are
consistent with our available records.
Signature Over Printed Name of Employer / Authorized Representative
Official Capacity / Designation
Date Signed (month-day-year)
PART III - CONSENT TO ACCESS PATIENT RECORD/S
I hereby consent to the examination by PhilHealth of the patient's medical records for the purpose of verifying the veracity of this claim.
I hereby hold PhilHealth or any of its officers, employees and/or representatives free from any and all liabilities relative to the herein-mentioned
consent which I have voluntarily and willingly given in connection with this claim for reimbursement before PhilHealth.
Signature Over Printed Name of Member/ Patient/ Authorized Representative
(Date Signed (month-day-year)
Relationship of the
representative to the
member:/ patient:
Reason for signing on
behalf of the
member:/ patient:
Parent
Spouse
Child
Others, specify _______________
Sibling
Patient is incapacitated
Other reasons _______________
If patient/ representative is unable to write, put right
thumbmark. Patient/ representative should be assisted
by an HCI representative. Check the appropriate box:
Patient
Representative
PART IV - HEALTH CARE PROFESSIONAL INFORMATION
Accreditation No.
Accreditation No.
Signature Over Printed Name
Signature Over Printed Name
Date Signed (month-day-year)
Date Signed (month-day-year)
Accreditation No.
Signature Over Printed Name
Date Signed (month-day-year)
PART V - PROVIDER INFORMATION AND CERTIFICATION
I certify that services rendered were recorded in the patient's chart and health care institution records and that the herein information given are true and correct.
Signature Over Printed Name Authorized HCI Representative
Official Capacity / Designation
Date Signed (month-day-year)
