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Registration Form
PhilHealth application form for dialysis database
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Draft Version 1.0 : February 22, 2016
PHILHEALTH DIALYSIS DATABASE
Registration Form
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.
New Registration
1. PhilHealth Identification Number (PIN)
-
-
2. Name of CKD Patient
Last Name
3. Currently, I am a
4. Date of Birth
First Name
Principal Member
-
5. Sex
day
Middle Name
(example: DELA CRUZ JUAN JR SIPAG)
Dependent
-
month
Name Extension (JR/SR/III)
Male
Female
6. Civil Status:
year
7. Mailing Address
Unit/ Room No., Floor
Building Name
Barangay
Street
Lot/Block/House/Bldg. No.
City/Municipality
Province
8. Email Address
Subdivision/Village
Zip Code
Country
9. Mobile Number
10. Landline
11. Is the patient enrolled under the Z benefits?
PD First Policy
Yes
No
Kidney Transplantation
Yes
No
Yes
No
12. Previous availment under All Case Rates?
Kidney Transplantation
(month & year)
13. I started dialysis on
14. For HD: Type of dialyzer
Low flux
15. For PD: Current PD system
CAPD
High flux
CIPD-C
Others:
CIPD-M
CCPD
NIPD
I certify that the herein information given are true and correct.
17. Date
16. Signature/Thumbmark
Printed Name
month
day
18. PDD Registration No.
19. Registered by
Name of Health Care Institution
21. Registration Date
month
day
year
20. Accreditation No.
year
Reactivation
