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Republic of the Philippines PMRF

PHILIPPINE HEALTH INSURANCE CORPORATION PHILHEALTH MEMBER REGISTRATION FORM


Citystate Centre Building, 709 Shaw Boulevard, Pasig City (October 2013)
Healthline 441-7444 www.philhealth.gov.ph

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PhilHealth Identification Number (PIN)
IMPORTANT REMINDERS:
1. Your PhilHealth Identification Number (PIN) is your unique and permanent number.
2. The issuance of the PIN does not automatically qualify you or your dependents to be entitled to NHIP benefits.

9 FOR UPDATING
3. Always use your PIN in all transactions with PhilHealth. PURPOSE:
Please carefully read instructions at the back before accomplishing this form. FOR ENROLLMENT

9
1. MEMBER INFORMATION
Last Name First Name Name Extension (JR/SR/III) Middle Name

If Married Female, please write FULL MAIDEN NAME:


Last Name First Name Name Extension (JR/SR/III) Middle Name

9 Date of Birth (mm-dd-yyyy) 9Place of Birth (City/Municipality/Province)9Sex 9 Civil Status 9 Nationality 9Tax Identification No.(TIN)
Male Single Widow(er)
Female Married Legally Separated

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Permanent Address
Unit/Room No./Floor Building Name Lot/Block/House/Bldg. No. Street Subdivision/Village

Barangay City/Municipality Province Country Zip Code

9 9Mobile Number 9E-mail Address


Contact Information
Landline Number (Area Code + Tel. No.)

2. DECLARATION OF DEPENDENTS (Use separate sheet if necessary)


2.1 Legal Spouse
PhilHealth Identification Name Extension Date of Birth Sex
Last Name First Name (JR/SR/III)
Middle Name
Number (PIN) mm-dd-yyyy M/F

2.2 Children below 21 years old (unmarried & unemployed) and/or Children 21 years old and above with permanent disability
PhilHealth Identification
Last Name First Name
Name Extension
Middle Name Mark ¥ if with Date of Birth Sex
Number (PIN) (JR/SR/III) Disability mm-dd-yyyy M/F

Mark ¥ if with
2.3 Parents’ Details
PhilHealth Identification Name Extension Date of Birth
Father’s Last Name Father’s First Name (JR/SR/III)
Father’s Middle Name Permanent
Number (PIN) (mm-dd-yyyy)
Disability

PhilHealth Identification Name Extension Mother’s Maiden Middle Mark ¥ if with Date of Birth
Mother’s Maiden Last Name Mother’s First Name (JR/SR/III) Permanent
Number (PIN) Name (mm-dd-yyyy)
Disability

3. MEMBERSHIP CATEGORY

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3. 1 Formal Economy

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Private Government 3. 3 Indigent
Permanent/Regular Casual Contractor/Project-Based NHTS-PR
Enterprise Owner
Household Help / Kasambahay
Family Driver
3.2 Informal Economy 3.4 Sponsored
Migrant Worker Local Government Unit (Please specify): _________________________
Land Based Sea Based National Government Agency (Please specify): ____________________
Informal Sector (e.g. Market Vendor, Street Hawker, Pedicab/Tricycle Driver, etc.)
Others (Please specify): _____________________________________
(Please specify): _________________________________
Estimated Monthly Income: Php ________________________
No Income
3.5 Lifetime Member Date/Effectivity of Retirement:
Self-Earning Individual (e.g. Doctors, Lawyers, Engineers, Artists, etc.)
Retiree / Pensioner
(Please specify): _________________________________
With 120 months contribution
Estimated Monthly Income: Php ________________________ mm dd yyyy
and has reached retirement age
Filipino with Dual Citizenship
Naturalized Filipino Citizen
Citizen of other countries working/residing/studying in the Philippines
Organized Group (Please specify): _________________________

Under the penalty of law, I attest that the Please do not write on this portion. For filling-out by PhilHealth Officer:
information I provided in this Form are true

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and accurate to the best of my knowledge.

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Received by: ________________________ Date: ____________

Please affix right thumbmark if Evaluated by: ________________________ Date: ____________


Signature over Printed Name Date unable to write.
Republic of the Philippines PMRF
PHILIPPINE HEALTH INSURANCE CORPORATION PHILHEALTH MEMBER REGISTRATION FORM
Citystate Centre Building, 709 Shaw Boulevard, Pasig City (October 2013)
Healthline 441-7444 www.philhealth.gov.ph

9
PhilHealth Identification Number (PIN)
IMPORTANT REMINDERS:
1. Your PhilHealth Identification Number (PIN) is your unique and permanent number.
2. The issuance of the PIN does not automatically qualify you or your dependents to be entitled to NHIP benefits.

9 FOR UPDATING
3. Always use your PIN in all transactions with PhilHealth. PURPOSE:
Please carefully read instructions at the back before accomplishing this form. FOR ENROLLMENT

9
1. MEMBER INFORMATION
Last Name First Name Name Extension (JR/SR/III) Middle Name

If Married Female, please write FULL MAIDEN NAME:


Last Name First Name Name Extension (JR/SR/III) Middle Name

9 Date of Birth (mm-dd-yyyy) 9Place of Birth (City/Municipality/Province)9Sex 9 Civil Status 9 Nationality 9Tax Identification No.(TIN)
Male Single Widow(er)
Female Married Legally Separated

9
Permanent Address
Unit/Room No./Floor Building Name Lot/Block/House/Bldg. No. Street Subdivision/Village

Barangay City/Municipality Province Country Zip Code

9 9Mobile Number 9E-mail Address


Contact Information
Landline Number (Area Code + Tel. No.)

2. DECLARATION OF DEPENDENTS (Use separate sheet if necessary)


2.1 Legal Spouse
PhilHealth Identification Name Extension Date of Birth Sex
Last Name First Name (JR/SR/III)
Middle Name
Number (PIN) mm-dd-yyyy M/F

2.2 Children below 21 years old (unmarried & unemployed) and/or Children 21 years old and above with permanent disability
PhilHealth Identification
Last Name First Name
Name Extension
Middle Name Mark ¥ if with Date of Birth Sex
Number (PIN) (JR/SR/III) Disability mm-dd-yyyy M/F

Mark ¥ if with
2.3 Parents’ Details
PhilHealth Identification Name Extension Date of Birth
Father’s Last Name Father’s First Name (JR/SR/III)
Father’s Middle Name Permanent
Number (PIN) (mm-dd-yyyy)
Disability

PhilHealth Identification Name Extension Mother’s Maiden Middle Mark ¥ if with Date of Birth
Mother’s Maiden Last Name Mother’s First Name (JR/SR/III) Permanent
Number (PIN) Name (mm-dd-yyyy)
Disability

3. MEMBERSHIP CATEGORY

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3. 1 Formal Economy

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Private Government 3. 3 Indigent
Permanent/Regular Casual Contractor/Project-Based NHTS-PR
Enterprise Owner
Household Help / Kasambahay
Family Driver
3.2 Informal Economy 3.4 Sponsored
Migrant Worker Local Government Unit (Please specify): _________________________
Land Based Sea Based National Government Agency (Please specify): ____________________
Informal Sector (e.g. Market Vendor, Street Hawker, Pedicab/Tricycle Driver, etc.)
Others (Please specify): _____________________________________
(Please specify): _________________________________
Estimated Monthly Income: Php ________________________
No Income
3.5 Lifetime Member Date/Effectivity of Retirement:
Self-Earning Individual (e.g. Doctors, Lawyers, Engineers, Artists, etc.)
Retiree / Pensioner
(Please specify): _________________________________
With 120 months contribution
Estimated Monthly Income: Php ________________________ mm dd yyyy
and has reached retirement age
Filipino with Dual Citizenship
Naturalized Filipino Citizen
Citizen of other countries working/residing/studying in the Philippines
Organized Group (Please specify): _________________________

Under the penalty of law, I attest that the Please do not write on this portion. For filling-out by PhilHealth Officer:
information I provided in this Form are true

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and accurate to the best of my knowledge.

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Received by: ________________________ Date: ____________

Please affix right thumbmark if Evaluated by: ________________________ Date: ____________


Signature over Printed Name Date unable to write.