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Health Care Professional Provider Data Record
PhilHealth provider data record form for healthcare professionals
Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: Republic of the Philippines
PHILIPPINE HEALTH INSURANCE CORPORATION
Citystate Centre, 709 Shaw Boulevard, Pasig City
Healthline 637-9999 www.philhealth.gov.ph
FORM 1
PHILHEALTH COLLECTING AGENTS ACCREDITATION COMMITTEE
APPLICATION FORM
Application No.___________
BACKGROUND
COMPANY NAME: _____________________________a.k.a:_________________
Business Address: ______________________________________________________
Telephone No: _________________________ Fax No.:________________________
Email Address: ________________________
Head of Agency: ____________________________________________
Nature of Business: _______________________
No. of years in the business: ________________
Affiliation if any: _________________________
Number of branches:
Local: _____________________
Overseas: __________________
PROPOSAL
Local Collection
Manual Over-the-Counter
Collection/ Manual Reporting
Manual Over-the-Counter
Collection/ On-Line Reporting
On-Line Collection /
On-Line Reporting
Overseas Collection
Manual Over-the-Counter
Collection/ Manual Reporting
Manual Over-the-Counter
Collection/ On-line Reporting
On-Line Collection /
On-line Reporting
Received by:
Date:
