PhilHealth Member Registration Form
PMRF - UHC v.1 January 2020
PhilHealth
Your Partner in Health
REMINDERS:
- Your PhilHealth Identification Number (PIN) is your unique and permanent number.
- Always use your PIN in all transactions with PhilHealth.
- For Updating/Amendment check the appropriate box and provide details to be accomplished and submit corresponding supporting documents.
- Please read instructions at the back before filling-out this form.
PMRF
PHILHEALTH MEMBER REGISTRATION FORM
UHC v.1 January 2020
PHILHEALTH IDENTIFICATION NUMBER (PIN)*
PURPOSE:
Preferred KonSulTa Provider
I. PERSONAL DETAILS
| LAST NAME | FIRST NAME | NAME EXTENSION (Jr./Sr./III) | MIDDLE NAME | NO MIDDLE NAME (Check if applicable only) | MONONYM | |
|---|---|---|---|---|---|---|
| MEMBER* | ||||||
| MOTHER'S MAIDEN NAME* | ||||||
| SPOUSE (If Married) |
DATE OF BIRTH* | PLACE OF BIRTH (City/Municipality/Province/Country) Please indicate country if born outside the Philippines | PHILSYS ID NUMBER (Optional) |
SEX* | CIVIL STATUS* | CITIZENSHIP* | TAX PAYER IDENTIFICATION NUMBER (TIN) (Optional) |
II. ADDRESS and CONTACT DETAILS
PERMANENT HOME ADDRESS* Unit/Room No./Floor Building Name Lot/Block/Phase/House Number Street Name Subdivision (Purok) Barangay* Municipality/City* Province/State/Country (If abroad)* ZIP Code* MAILING ADDRESS Unit/Room No./Floor Building Name Lot/Block/Phase/House Number Street Name Subdivision (Purok) Barangay Municipality/City Province/State/Country (If abroad) ZIP Code | Home Phone Number (COUNTRY CODE + AREA CODE + TELEPHONE NUMBER) Mobile Number* Business (Direct Line) E-mail Address (Required for OFW) |
III. DECLARATION OF DEPENDENTS (Use additional form if necessary)
| LAST NAME | FIRST NAME | NAME EXT (Jr./Sr./III) | MIDDLE NAME | RELATIONSHIP | DATE OF BIRTH | CITIZENSHIP | NO MID. NAME | MONONYM | PWD | HCI | |
|---|---|---|---|---|---|---|---|---|---|---|---|
IV. MEMBER TYPE
DIRECT CONTRIBUTOR
PRA SRRV No.
ACR I-Card No.
INDIRECT CONTRIBUTOR
PWD ID No.
For PhilHealth Use only:
PROFESSION: (Except Employed, Lifetime Members and Sea-based Migrant Worker)
MONTHLY INCOME:
PROOF OF INCOME:
This form may be reproduced and is not for saleContinue at the back
PhilHealth
Your Partner in Health
REMINDERS:
- Your PhilHealth Identification Number (PIN) is your unique and permanent number.
- Always use your PIN in all transactions with PhilHealth.
- For Updating/Amendment check the appropriate box and provide details to be accomplished and submit corresponding supporting documents.
- Please read instructions at the back before filling-out this form.
PMRF
PHILHEALTH MEMBER REGISTRATION FORM
UHC v.1 January 2020
PHILHEALTH IDENTIFICATION NUMBER (PIN)*
PURPOSE:
Preferred KonSulTa Provider
I. PERSONAL DETAILS
| LAST NAME | FIRST NAME | NAME EXTENSION (Jr./Sr./III) | MIDDLE NAME | NO MIDDLE NAME (Check if applicable only) | MONONYM | |
|---|---|---|---|---|---|---|
| MEMBER* | ||||||
| MOTHER'S MAIDEN NAME* | ||||||
| SPOUSE (If Married) |
DATE OF BIRTH* | PLACE OF BIRTH (City/Municipality/Province/Country) Please indicate country if born outside the Philippines | PHILSYS ID NUMBER (Optional) |
SEX* | CIVIL STATUS* | CITIZENSHIP* | TAX PAYER IDENTIFICATION NUMBER (TIN) (Optional) |
II. ADDRESS and CONTACT DETAILS
PERMANENT HOME ADDRESS* Unit/Room No./Floor Building Name Lot/Block/Phase/House Number Street Name Subdivision (Purok) Barangay* Municipality/City* Province/State/Country (If abroad)* ZIP Code* MAILING ADDRESS Unit/Room No./Floor Building Name Lot/Block/Phase/House Number Street Name Subdivision (Purok) Barangay Municipality/City Province/State/Country (If abroad) ZIP Code | Home Phone Number (COUNTRY CODE + AREA CODE + TELEPHONE NUMBER) Mobile Number* Business (Direct Line) E-mail Address (Required for OFW) |
III. DECLARATION OF DEPENDENTS (Use additional form if necessary)
| LAST NAME | FIRST NAME | NAME EXT (Jr./Sr./III) | MIDDLE NAME | RELATIONSHIP | DATE OF BIRTH | CITIZENSHIP | NO MID. NAME | MONONYM | PWD | HCI | |
|---|---|---|---|---|---|---|---|---|---|---|---|
IV. MEMBER TYPE
DIRECT CONTRIBUTOR
PRA SRRV No.
ACR I-Card No.
INDIRECT CONTRIBUTOR
PWD ID No.
For PhilHealth Use only:
PROFESSION: (Except Employed, Lifetime Members and Sea-based Migrant Worker)
MONTHLY INCOME:
PROOF OF INCOME:
This form may be reproduced and is not for saleContinue at the back
V. UPDATING/AMENDMENT
| Please check: | FROM | TO |
|---|---|---|
Under penalty of law, I hereby attest that the information provided, including the documents I have attached to this form, are true and accurate to the best of my knowledge. I agree and authorize PhilHealth for the subsequent validation, verification and for other data sharing purposes only under the following circumstances:
- As necessary for the proper execution of processes related to the legitimate and declared purpose;
- The use or disclosure is reasonably necessary, required or authorized by or under the law; and,
- Adequate security measures are employed to protect my information.
No signature yet
Member's Signature over Printed Name
Date
Please affix right thumbmark if unable to write
FOR PHILHEALTH USE ONLY
RECEIVED BY:
Full Name:
PRO/LHIO/Branch:
Date & Time:
INSTRUCTIONS
- All information should be written in UPPER CASE/CAPITAL LETTERS. If the information is not applicable, write "N/A."
- All fields are mandatory unless indicated as optional. By affixing your signature, you certify the truthfulness and accuracy of all information provided.
- A properly accomplished PMRF shall be accompanied by a valid proof of identity for first time registrants, and supporting documents to establish relationship between member and dependent/s for updating or request for amendment.
- On the PURPOSE, check the appropriate box if for Registration or for Updating/Amendment of information.
- Indicate preferred KonSulTa provider near the place of work or residence.
- For PERSONAL DETAILS, all name entries should follow the format given below. Check the appropriate box if registrant has no middle name and/or with single name (mononym).
| LAST NAME | FIRST NAME | NAME EXTENSION (Jr./Sr./III) | MIDDLE NAME |
|---|---|---|---|
| SANTOS | JUAN ANDRES | III | DELA CRUZ |
- Indicate registrant's/member's name as it appears in the birth certificate.
- The full mother's maiden name of registrant/member must be indicated as it appears in the birth certificate.
- Indicate the full name of spouse if registrant/member is married.
- Indicate the complete permanent and mailing addresses and contact numbers.
- For updating/amendment, check the appropriate box to be updated/amended and indicate the correct data.
- For MEMBER TYPE, check the appropriate box which best describes your current membership status.
- For Direct Contributors, except employed, sea-based migrant workers and lifetime members, indicate the profession, monthly income and proof of income to be submitted.
- For Self-earning individuals, Kasambahays and Family Drivers, indicate the actual monthly income in the space provided.
- In declaring dependents, provide the full name of the living spouse, children below 21 years old, and parents who are 60 years old and above totally dependent to the member.
- Dependents with disability shall be registered as principal members in accordance with Republic Act 11228 on mandatory PhilHealth coverage for all persons with disability (PWD).
- The registrant must affix his/her signature over printed name (or right thumbmark if unable to write) and indicate the date when the PMRF was signed.