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SCAF Software Certification Application Form

PhilHealth application form for software certification

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CERTIFICATION
APPLICATION FORM
I.

Reference #

_____________

Application Date:

____/____/____

HEALTH CARE INSTITUTION (HCI) INFORMATION

1 Name
2 Address
3 PhilHealth Accreditation No.

7 Cellphone No.

4 Name of Head / Representative

8 Landline No.

5 Designation of Head / Representative

9 Email Address for
Notification

 In-House Developed  Outsourced
II. SERVICE PROVIDER INFORMATION (FOR OUTSOURCED SOFTWARE SOLUTION ONLY)
6 Software Solution Type (Please check)

10 Name of Outsourcing Company
11 Business Address
12 Name of Business Owner/ Authorized
Representative

14 Contact No.

13 Designation of Head / Representative

15 Email Address

16 PhilHealth Identification Number
(PIN) or PhilHealth Employer Number
(PEN)

III. SOFTWARE SOLUTION (FOR IN-HOUSE AND OUTSOURCED SOFTWARE SOLUTION)
17 Data Collection Services Applied For
 All Case Rates
 Newborn Care Package
(Please check applicable services)
 Animal Bite Treatment Package  Outpatient HIV/AIDS Treatment Package
 Dialysis Package
 Outpatient Malaria Package
 Maternal-Care Package
 TB-Dots Package
 Z-Benefits
 Primary Care Benefit (PCB) Package
 Others, please specify __________________
__________________
19 Version No.

18 Name/Title

HCI CERTIFICATION
The UNDERSIGNED hereby certifies that:
1.
2.
3.

I am the official officer or representative of the HCI named in Item I – Health Care Institution Information, authorized
to apply for Software Certification in PhilHealth and receive email notifications from PhilHealth.
I am endorsing the named service provider in Item II – Service Provider, if applicable.
All the above information is true and correct to the best of my knowledge and belief.

_____________________________________________________
Name and Signature of HCI Head/Authorized Representative

________________
Date Signed

TO BE FILLED UP BY PHILHEALTH PERSONNEL
Date
Received

Received By:
(Name and Signature)

__/__/____

Time
Received

______  am  pm

Page 1 of 2 of Annex A – Software Certification Application Form (as of July 2017)

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GUIDELINES IN FILLING OUT THE SOFTWARE APPLICATION FORM
Name
Name of the HCI that appears in its accreditation
Address
Complete address of the HCI that appears in its accreditation
PhilHealth Accreditation No.
Number that appears in its accreditation
Complete name of the HCI Head like Chief of Hospital. The
Name of Head / Representative
HCI Head may have authorized representative in his behalf.
Designation of Head /
Title of the HCI Head or authorized representative
Representative
In-house refers to a computer software that is done or developed
within the health care institution; Outsourced refers to the
Software Solution Type
purchase of a computer software, solution, or product from an
outside source like service provider.
Cellphone No.
Cellular phone number of the HCI
Landline No.
Telephone number of the HCI
Email address of the HCI where notifications or messages can be
Email Address for Notification
sent
Name of Outsourcing Company
Name of service provider if software solution is outsourced
Business Address
Complete address of the service provider
Complete name of the Head or authorized representative of the
Name of Head / Representative
Service Provider
Designation of Head /
Title of the Head or authorized representative of the service
Representative
provider
Cellphone Number and/or landline number of the service
Contact No.
provider
Email Address
Email address of the service provider
PhilHealth Identification Number

16 (PIN) or PhilHealth Employer
Number (PEN)

Data Collection Services Applied
17
For
18 Name/Title
19 Version No.

The assigned PIN for individual Outsourcing Service Provider or
PEN for a firm Outsourcing service provider
Services used by the health care institutions to submit or transmit
data for all case rates, special benefit packages or Z-Benefits,
outpatient benefit packages, and others as defined by PhilHealth.
Name or title of the system or software to be verified
Version reference number or code of the system or software to
be verified

Page 2 of 2 of Annex A – Software Certification Application Form (as of July 2017)

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