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This form may be reproduced and is NOT FOR SALE CF1 Claim Form revised February 2010 IMPORTANT REMINDERS PLEASE WRITE IN CAPITAL LETTERS AND CHECK THE APPROPRIATE BOXES. For local confinement this form together with CF2 and other supporting documents should be filed within60 DAYS from date of discharge. Only one 1 original copy of this Form is required per claim application/availment. 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 Member/Representative to fill out all items with the assistance of the Health Care Provider 2. Member Category 1. PhilHealth Identification No. PIN Employed 3. Name of Member Last Name Sponsored Government First Name Middle Name 4. For confinement abroad this form together with other supporting documents should be filed within180 DAYS from date of discharge. Only one 1 original copy of this Form is required per claim application/availment. 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 Member/Representative to fill out all items with the assistance of the Health Care Provider 2. Member Category 1. PhilHealth Identification No* PIN Employed 3. Name of Member Last Name Sponsored Government First Name Middle Name 4. Mailing Address OFW Private example Dela Cruz Juan Jr. Sipag Individually Paying Lifetime 5. Date of Birth House Number Name of Street City / Municipality Month Barangay Province Day Year ZIP Code 6. Contact Information if available E-mail Address Mobile No* Landline No* 7. Name of Patient Patient is the Member Patient is a Dependent Child Parent Spouse 9. CERTIFICATION OF MEMBER I hereby certify that the herein information are true and correct and may be used for any legal purpose. Signature Over Printed Name of Member 10. Relationship of the Representative to the Member Date Signed month-day-year Guardian / Next of Kin 11. Reason for Signing on Behalf of the Member Member is Abroad / Out-of-Town 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 and Official Address Business Name of Employer Building Number and Street Name 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.

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