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Philhealth: Provider'S Certification Health Care

This document is a PhilHealth claim form for a hospital stay. It contains sections for the hospital to provide information about the facility, patient, and charges including room and board, drugs, lab tests, and procedures. There are also sections for doctors to provide diagnosis, services performed, and professional charges. The patient certifies any deductions made from hospital or professional charges or payments made for outside medicines or labs during the confinement period.

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Joynilenge Colipano Lavador
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© © All Rights Reserved
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70 views2 pages

Philhealth: Provider'S Certification Health Care

This document is a PhilHealth claim form for a hospital stay. It contains sections for the hospital to provide information about the facility, patient, and charges including room and board, drugs, lab tests, and procedures. There are also sections for doctors to provide diagnosis, services performed, and professional charges. The patient certifies any deductions made from hospital or professional charges or payments made for outside medicines or labs during the confinement period.

Uploaded by

Joynilenge Colipano Lavador
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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This form may be reproduced and is NOT FOR SALE

PHILHEALTH HEALTH CARE


CLAIM FORM 2 PROVIDER'S CERTIFICATION
Revised May 2000
Note: This form together with Claim Form 1 should be filed with PhilHealth within 60 calendar days from date of discharge.

PART I - HOSPITAL DATA AND CHARGES ( Hospital to Fill in All Items )


1. PhilHealth Accreditation No. 2. Accreditation Category Primary Secondary Tertiary Ambulatory
3. Name of Hospital/Ambulatory Clinic

4. Address of Hospital/Ambulatory Clinic


No., Street Barangay

Municipality/City Province Zip Code

5. Name of Member and Identification


Last Name First Name

Middle Name
Identification No.
6. Address of Member
No., Street Barangay

Municipality/City Province Zip Code

7. Name of Patient 8. Age 10. Admission Diagnosis


Last Name

First Name 9. Sex


M
Middle Name
F
11. Confinement Period m m d d y y y y m m d d y y y y
a. Date Admitted c. Date Discharged e. Claimed No.of Days
AM/PM AM/PM
AM/PM f. Date of Death m m d d y y y y
b. Time Admitted : d. Time Discharged : (If Applicable)
12. Hospital/Ambulatory Services ACTUAL HOSPITAL/ BENEFIT CLAIM
AMBULATORY CHARGES HOSPITAL PATIENT
REDUCTION CODE
a. Room and Board
b. Drugs and Medicines ( Part III for details )
c. X-ray/Lab. Test/Others ( Part IV for details )
d. Operating Room Fee
e. Medicines bought & laboratory performed
outside hospital during confinement period
TOTAL
13. CERTIFICATION of HOSPITAL/AMBULATORY CLINIC: I certify that the services rendered are duly recorded in the patient's chart and that the information
given in this form are true and correct.

Signature Over Printed Name of Authorized Representative Date Signed Official Capacity
PART II - PROFESSIONAL DATA AND CHARGES ( Doctor/s to Fill in Respective Portions )
14. Complete Final Diagnosis
FOR PHILHEALTH USE

Relative Unit Value


15. Case Type Ordinary Intensive Catastrophic
16. Name of Attending Physician Signature & Date Signed Illness Code

17.PHIC Accreditation No. 18. BIR/TIN No. - - Reduction Code


19. Services Performed 20. Actual Benefit Claim
Professional Charges Physician Patient
P P P

21. Name of Surgeon Signature & Date Signed Reduction Code

22.PHIC Accreditation No. 23. BIR/TIN No. - -


24. Services Performed 25. Actual Benefit Claim
Professional Charges Surgeon Patient
P P P
Date of Operation
26. Name of Anesthesiologist Signature&&Date
Signature DateSigned
Signed Reduction Code

27.PHIC Accreditation No. 28. BIR/TIN No. - -


29. Services Performed 30. Actual Benefit Claim
Professional Charges Physician Patient
P P P
NOTE:Anyone who supplies false or incorrect information requested by this or a related form or commits misrepresentation shall be subject to criminal,civil or administrative prosecution
under the law.All data required on this form are necessary for adjudication of the claim.PhilHealth will not adjudicate any claim where forms are not properly or completely accomplished.
PART III - DRUGS AND MEDICINES
Preparation
(cap/sy/inj/tab with Unit Actual Benefit Claim
Generic name Brand ml/mg/gm content) Qty. Price Charges Hospital Patient

1.
2.
3.
4.
5.
6.
7.
8.
9.
10
11.
12.
13.
14.
15.
TOTAL
NOTE: Official Receipts for drugs and medicines purchased by patient must be attached to this claim.
PART IV - X-RAY, LABORATORIES AND OTHERS
Unit Actual Benefit Claim
Particulars Qty. Price Charges Hospital Patient
A. X-ray/Lab.

1.
2.
3.
4.
5.
B. Supplies

1.
2.
3.
4.
5.
C. Others

1.
2.
3.
4.
5.
TOTAL
NOTE: Official Receipts for laboratory procedures performed outside the hospital during this confinement period must be attached to this claim.
PART V - CERTIFICATION of PATIENT/MEMBER
I hereby certify that:
The amount of P was deducted from the hospital charges.
The amount of P was deducted from the professional fee charges.
The amount of P was paid for medicines/lab. acquired outside the hospital during this confinement
( Official Receipts attached ).
No deduction was made from the hospital charges.
No deduction was made from the professional fee charges.

Date Signature Over Printed Name of Patient/Member

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