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Get PH CF3 2010

DAYS FROM DATE OF DISCHARGE. FOR LEVEL 1 FACILITY, THIS FORM SHALL BE REQUIRED FOR ALL BENEFIT CLAIMS. FOR LEVELS 2, 3 AND 4 FACILITIES, THIS FORM IS REQUIRED IN CASES OF: 1) EMERGENCY/TRANSFERRED 2) LESS THAN 24 HOURS ADMISSION 3) CASE TYPE 'D' DIAGNOSIS. THIS FORM SHALL BE REQUIRED FOR ALL CLAIMS ON MATERNITY CARE PACKAGE. PART I - PATIENT'S CLINICAL RECORD 1. PhilHealth Accreditation No. (PAN) - Institutional Health Care Provider: 2. Name of Patient 3. Chief Complaint / Reason for Admissio.

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