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CF2 Provider Information
PhilHealth provider information claim form
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CF2
(Claim Form 2)
revised November 2013
Series #
IMPORTANT REMINDERS:
PLEASE WRITE IN CAPITAL LETTERS AND CHECK THE APPROPRIATE BOXES.
This form together with other supporting documents should be filed within sixty (60) calendar days from date of discharge.
All information, fields and tick boxes required in this form are necessary. 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 - HEALTH CARE INSTITUTION (HCI) INFORMATION
1. PhilHealth Accreditation Number (PAN) of Health Care Institution:
2. Name of Health Care Institution:
3. Address:
Province
City/Municipality
Building Number and Street Name
PART II - PATIENT CONFINEMENT INFORMATION
1. Name of Patient:
Last Name
First Name
Name Extension (JR/SR/III)
Middle Name
(example: DELA CRUZ JUAN JR SIPAG)
2. Was patient referred by another Health Care Institution (HCI)?
NO
YES
3. Confinement Period:
Name of Referring Health Care Institution
a. Date Admitted:
month
c. Date Discharged:
day
month
4. Patient Disposition: (select only 1)
hour
year
e. Expired,
hour
Date:
month
b. Recovered
AM
AM
PM
min
Time:
day
Zip Code
PM
min
:
d. Time Discharged:
day
a. Improved
:
year
-
Province
City/Municipality
Building Number and Street Name
b. Time Admitted:
-
year
:
hour
PM
AM
min
f. Transferred/Referred
Name of Referral Health Care Institution
c. Home/Discharged Against Medical Advise
Building Number and Street Name
d. Absconded
City/Municipality
Province
Zip Code
Reason/s for referral/transfer:
5. Type of Accommodation:
Private
Non-Private (Charity/Service)
6. Admission Diagnosis/es:
7. Discharge Diagnosis/es (Use additional CF2 if necessary):
Diagnosis
ICD-10 Code/s
Related Procedure/s (if there's any)
a.
RVS Code
Date of Procedure
Laterality (check applicable boxes)
i.
Left
Right
Both
ii.
Left
Right
Both
iii.
Both
Right
Both
Left
Right
Both
iii.
Left
Right
Both
i.
Left
Right
Both
ii.
Left
Right
Both
iii.
Left
Right
Both
i.
Left
Right
Both
ii.
Left
Right
Both
iii.
d.
Right
Left
ii.
c.
Left
i.
b.
Left
Right
Both
8. Special Considerations:
a. For the following repetitive procedures, check box that applies and enumerate the procedure/session dates [mm-dd-yyyy]. For chemotherapy, see guidelines.
Hemodialysis
Blood Transfusion
Peritoneal Dialysis
Brachytherapy
Radiotherapy (LINAC)
Chemotherapy
Radiotherapy (COBALT)
Simple Debridement
b. For Z-Benefit Package
Z-Benefit Package Code:
c. For MCP Package (enumerate four dates [mm-dd-yyyy] of pre-natal check-ups)
3
2
1
d. For TB DOTS Package
Intensive Phase
4
Maintenance Phase
e. For Animal Bite Package (write the dates [mm-dd-yyyy] when the following doses of vaccine were given) NOTE: Anti Rabies Vaccine (ARV), Rabies Immunoglobulin (RIG)
Day 0 ARV
f. For Newborn Care Package
RIG
Day 7 ARV
Day 3 ARV
Essential Newborn Care
Newborn Hearing Screening Test
Others (Specify)
Newborn Screening Test For Newborn Screening,
please attach NBS Filter Sticker here
For Essential Newborn Care, (check applicable boxes)
Immediate drying of newborn
Timely cord clamping
Weighing of the newborn
BCG vaccination
Early skin-to-skin contact
Eye prophylaxis
Vitamin K administration
Non-separation of mother/baby for early breastfeeding initiation
g. For Outpatient HIV/AIDS Treatment Package
Laboratory Number:
9. PhilHealth Benefits
ICD 10 or RVS Code: a. First Case Rate
b. Second Case Rate
Hepatitis B vaccination
10. Professional Fees / Charges (Use additional CF2 if necessary):
Accreditation Number / Name of Accredited Health Care Professional / Date Signed
Accreditation No.:
-
Details
No co-pay on top of PhilHealth Benefit
Signature Over Printed Name
Date Signed:
-
-
month
day
Accreditation No.:
With co-pay on top of PhilHealth Benefit P
year
-
No co-pay on top of PhilHealth Benefit
Signature Over Printed Name
Date Signed:
-
-
month
day
Accreditation No.:
With co-pay on top of PhilHealth Benefit P
year
-
No co-pay on top of PhilHealth Benefit
Signature Over Printed Name
Date Signed:
-
With co-pay on top of PhilHealth Benefit P
-
month
day
year
PART III - CERTIFICATION OF CONSUMPTION OF BENEFITS AND CONSENT TO ACCESS PATIENT RECORD/S
NOTE: Member/Patient should sign only after the applicable charges have been filled-out
A. CERTIFICATION OF CONSUMPTION OF BENEFITS
PhilHealth benefit is enough to cover HCI and PF charges.
No purchases of drugs/medicines, supplies, diagnostics, and co-pay for professional fees by the member/patient.
Total Actual Charges*
Total Health Care Institution Fees
Total Professional Fees
Grand Total
The benefit of the member/patient was completely consumed prior to co-pay OR the benefit of the member/patient is not completely consumed BUT with
purchases/expenses for drugs/medicines, supplies, diagnostics and others.
a.) The total co-pay for the following are:
Total Actual
Charges*
Amount after Application of
Discount (i.e., personal discount,
Senior Citizen/PWD
PhilHealth Benefit
Total Health Care
Institution Fees
Amount after PhilHealth Deduction
Amount P
Paid by (Check all that applies):
Member/Patient
HMO
Others (i.e., PCSO, Promissory note, etc.)
Total Professional
Fees
Amount P
Paid by (Check all that applies):
(for accredited
and nonaccredited
professionals)
Member/Patient
HMO
Others (i.e., PCSO, Promissory note, etc.)
b.) Purchases/Expenses NOT included in the Health Care Institution Charges
Total cost of purchase/s for drugs/medicines and/or medical supplies bought by
the patient/member within/outside the HCI during confinement
None
Total Amount P
Total cost of diagnostic/laboratory examinations paid for by the patient/member
done within/outside the HCI during confinement
None
Total Amount P
*NOTE: Total Actual Charges should be based on Statement of Account (SoA)
B. 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:
Spouse
Child
Sibling
Others, Specify
Reason for signing on
behalf of the member/patient:
Patient is Incapacitated
Parent
If patient/representative is unable to write,
put right thumbmark. Patient/representative
should be assisted by an HCI representative.
Check the appropriate box:
Patient
Other Reasons:
Representative
PART IV - CERTIFICATION OF HEALTH CARE INSTITUTION
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 of Authorized
HCI Representative
Date Signed:
Official Capacity / Designation
month
day
year
