This form may be reproduced

Republic of the Philippines and is NOT FOR SALE

PHILIPPINE HEALTH INSURANCE CORPORATION
Citystate Center 709 Shaw Boulevard, Pasig City
Call Center (02) 441-7442 ? Trunkline (02) 441-7444
CF2
(Claim Form 2)
[Link] Revised September 2018
email: actioncenter@[Link]
Series #

IMPORTANT REMINDERS
PLEASE WRITE IN CAPITAL LETTERS AND CHECK THE APPROPRIATE BOXES.
This form together with other supporting documents should be filed within sixty (60) calendar days from date of discharge.
All information, fields and tick boxes required in this form are necessary. 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 - HEALTH CARE INSTITUTION (HCI) INFORMATION

1. Philhealth Accreditation Number (PAN) of Health Care Institution: M 0 6 0 2 1 8 2 7

2. Name of Health Care Institution: PAN-AY RURAL HEALTH UNIT

3. Address: PANAY CAPIZ

Building Number and Street Name City/Municipality Province

PART II - PATIENT CONFINEMENT INFORMATION

1. Name of Patient: BESANA PHOEBE JOY ANDRADE

Last Name First Name Name Extension (JR/SR/III) Middle Name (Example: DELA CRUZ JUAN JR SIPAG)

2. Was patient referred by another Health Care Institution (HCI)?

NO YES
Name of Referring Health Care Institution Building Number and Street Name City/Municipality Province Zip Code

3. Confinement Period: a. Date Admitted 0 9 - 1 3 - 2 0 2 1 b. Time Admitted: 0 8 : 3 0 AM PM

month day year hour min

c. Date Discharge 0 9 - 1 5 - 2 0 2 1 d. Time Discharge: 0 1 : 0 0 AM PM

month day year hour min

4. Patient Disposition: (select only 1)

a. Improved e. Expired, Date - - Time: : AM PM
b. Recovered f. Transfered/Refered:
Name of Referral Health Care Institution
c. Home/Discharged Againts Medical Advice
Building Number and Street Name City/Municipality Province Zip Code
d. Absconded Reason/s for referral/transfer:
5. Type of Accomodation: Private Non-Private(Charity/Service)

6. Admission Diagnosis/es:
G1P1 2001 PREGNANCY UTERINE 38 WEEKS AOG CEPHALIC IN LABOR

7. Discharge Diagnosis/es (Use additional CF2 if necessary):

Diagnosis ICD-10 Related Procedure/s (if there's any) RVS Date of Procedure Laterality (check applicable boxes)
a. i. ROUTINE OBSTETRIC CARE
INCLUDING PRENATAL, DELIVERY
Single live birth Z37.0 AND NEWBORN SERVICES OF MCP01 01-01-1970 Left Right Both
NON-HOSPITAL FACILITIES
(MATERNITY CARE PACKAGE)
ii. Left Right Both
iii. Left Right Both
b. Spontaneous vertex delivery i.
(NORMAL SPONTANEOUS O80.0 Left Right Both
CEPHALIC DELIVERY)
ii. Left Right Both
iii. Left Right Both
c. Singleton, born outside hospital Z38.1 i. Left Right Both
ii. Left Right Both
iii. Left Right Both
d. i. Left Right Both
ii. Left Right Both
iii. Left Right Both

[Link] Consideration
a. For the following repetitive procedures, check box that applies and enumerate the procedure/session dates [mm-dd-yyyy]. For chemotherapy, see guidelines
Hemodialysis Blood Tranfusion

Peritoneal Dialysis Brachytherapy

Radiotherapy (LINAC) Chemotherapy

Radiotherapy (COBALT) Simple Debridement

b. For Z-Benefit Package Z-Benefit Code:

c. For MCP Package (enumerate four dates [mm-dd-yyyy])of pre-natal check-ups

1 01-19-2021 2 02-16-2021 3 06-02-2021 4 08-31-2021

d. For TB DOTS Package Intensive Phase Maintenance Phase

e. For Animal Bite Package(write the dates [mm-dd-yyyy]when the following doses of vaccine were given) NOTE: Anti Rabies Vaccine(ARV), Rabies Immunoglobulin (RIG)

Day 0 ARV Day 3 ARV Day 7 ARV RIG Other Specify

For Newborn Screening,
f. For Newborn Care Package Essential Newborn Care Newborn Hearing Screening Test New Screening Test please attach NBS Filter Sticker here
 For Essential Newborn Care, (check applicable boxes)

Immidiate drying of newborn Timely cord clamping Weighing of the newborn BCG Vaccination Hepatitis B vaccination
Early skin-to-skin contact Eye prophylaxis Vitamin K administration Non-separation of mother/baby for early breastfeeding initiation

[Link] Outpatient HIV/AIDS Treatment Package Laboratory Number:

[Link] Benefits

ICD 10 or RVS Code: a. First Case Rate: MCP01 b. Second Case Rate:
10. Professional Fees / Charges(Use additional CF2 if necessary:)
Accreditation Number / Name of Accredited Health Care Professional / Date Signed Details

Accreditation No.: 1 2 3 4 5 6 7 8 9 1 2 3

No co-pay on top of Philhealth Benefit

DOCTOR FN DOCTOR MN DOCTOR LN
With co-pay on top of Philhealth Benefit. P
Signiture Over Printed Name

Date Signed: 01-01-1970

PART III - CERTIFICATION OF CONSUMPTION OF BENEFITS AND CONSENT TO ACCESS PATENT RECORD/S
NOTE: Member/Patient should sign only after the applicable charges have been filled-out

A. CERTIFICATION OF CONSUMPTION OF BENEFITS

PhilHealth benefit is enough to cover HCI and PF charges.
No purchases of drugs/medicine,supplies,diagnostics, and co-pay for professional fees by the member/patient.

Total Actual Charge

Total Health Care Institution Fees 4800

Total Professional Fees 4800

Grand Total 8000

The benefit of the member/patient was completely consumed prior to co-pay OR the benefit of the member/patient is not completely consumed BUT with
purchases/expenses for drugs/medicines, supplies, diagnostics and others
a.) The total co-pay for the following are:
Amount after Application of
Total Actual Discount(i.e, Personal
PhilHealth Benefit Amount after PhilHealth Deduction
Charge Discount,
Senior Citizen/PWD
Amount P
Paid by (Check all that applies)
Total Health Care
Institution Fees Member/Patient HMO
Others(i.e.,PCSO,Promissory note, etc.)
Amount P
Total Professional Paid by (Check all that applies)
Fees (for accredited
and
non-accredited Member/Patient HMO
professionals) Others(i.e.,PCSO,Promissory note, etc.)

b.) Purchase/Expenses NOT included in the Health Care Institution Charges

Total cost of purchase/s for drugs medicines and/or medical supplies bought by
None Total Amount?P
the patient/member within/outside the HCI during confinement
Total cost of diagnostic/laboratory examinations paid for by the patient/member
None Total Amount?P
done within/outside the HCI during confinement

*NOTE: Total Actual/ Charges should be based on Statement of Account (SOA)

[Link] TO ACCESS PATIENT RECORDS

I hereby consent to the examination by PhilHealth of the patient's medical records for the purpose of verifying the veracity of this claim.
I hereby hold PhilHealth or any of its officers, employees and/or representatives free from any and all liabilities relative to the herein-mentioned consent which I have voluntarily
and willingly given in connection with this claim for reimbursement before Philhealth.

PHOEBE JOY ANDRADE BESANA

Signature Over Printed Name of the Member/Patient/Authorized Representative
Date Signed: 0 9 - 1 5 - 2 0 2 1
Month - Day - Year

Relationship of the Spouse Child Parent If patient/representative is unable to write,

representative to the member/ put right thumbmark. Patient/representative
patient: Sibling Other, Specify should be assisted by an HCI representative.
Patient is Incapacitated Check the appropriate box:
Reason for signing on
behalf of the member/patient: Other Reason: Patient Representative

PART IV - CERTIFICATION OF HEALTH INSTITUTION

I certify that services rendered were recorded in the patient's chart and health care institution records and that the herein information given are true and correct.

Signature Over Printed Name of Authorized Official Capacity / Designation Date Signed: - -
HCI Representative month day year