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PhilHealth RF-1 Employer Report Form

The document is a remittance report form for the Philippine Health Insurance Corporation (PhilHealth) used by employers to report employee information and contributions. It includes sections for employer details, employee identification, and acknowledgment of the information provided. The form must be completed accurately and is subject to legal penalties for false information.

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hr.payroll3
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29 views3 pages

PhilHealth RF-1 Employer Report Form

The document is a remittance report form for the Philippine Health Insurance Corporation (PhilHealth) used by employers to report employee information and contributions. It includes sections for employer details, employee identification, and acknowledgment of the information provided. The form must be completed accurately and is subject to legal penalties for false information.

Uploaded by

hr.payroll3
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLSX, PDF, TXT or read online on Scribd

Republic of the PhilippinesPHILIPPINE HEALTH INSURANCE CORPORATION EMP

RF-1
Revised February 2014

1
PHILHEALTH NO. 0 0 3 0 0 0 0 3 0 7 6 6
EMPLOYER TIN 0 0 8 8 7 0 5 8 7
2 COMPLETE EMPLOYER NAME: HOME HEALTH CARE PLACEMENTS INC
COMPLETE MAILING ADDRESS: QUEZON CITY SECOND DISTRICT

TELEPHONE NUMBER: EMAIL ADDRESS:


6 7
EMPLOYEES INFORMATION
PHILHEALTH IDENTIFICATION NUMBER

(PIN) LAST NAME FIRST NAME NAME EXT. MIDDLE NAME


(SR./JR.)

10 .

12 13
ACKNOWLEDGEMENT RECEIPT (PAR/POR/TRANSACTION REFERENCE NO.)
Indicate Total Number
of employees per page ACKNOWLEDGEMENT
APPLICABLE PERIOD REMITTED AMOUNT TRANSACTION DATE
RECEIPT

16 UNDER THE PENALTY OF THE LAW, I HEREBY ATTEST THAT THE ABOVE INFORMATIO

Signature over printed name Official Designatio


PLEASE READ INSTRUCTIONS (FOR EACH NUMBERED BOX) AT THE BACK BEFORE AC
This form may be reproduced and is not for sale
ANCE CORPORATION EMPLOYER’S REMITTANCE REPORTHealthline 441-7444 [Link] actioncenter@[Link]
FOR PHILHEALTH USE

Date Received: Action taken:


By:
Signature Over Printed Name

3 EMPLOYER TYPE 4 REPORT TYPE 5 APPLICABLE PERIOD

PRIVATE REGULAR RF-1


GOVERNMENT ADDITION TO PREVIOUS RF-1
HOUSEHOLD DEDUCTION TO PREVIOUS RF-1

8 Fill out this portion only if 9 10 NHIP PREMIUM 11


ORMATION declared employee/s has not CONTRIBUTION EMPLOYEE STATUS
yet been issued his/her PIN
MIDDLE NAME DATE OF BIRTH SEX MONTHLY PS ES S-Separated, NE-No Earnings, NH-
(mm-dd-yyyy) SALARY Newly Hired / Effectivity Date
(M/F) BRACKET

14 15 PREPARED BY:
ERENCE NO.) SUBTOTAL (PS + ES)
To be accomplished on every page)
SIGNATURE OVER PRINTED NAME
NO. OF EMPLOYEES GRAND TOTAL (PS + ES)
(To be accomplished on every page) OFFICIAL DESIGNATION

DATE
HAT THE ABOVE INFORMATION PROVIDED HEREIN ARE TRUE AND CORRECT.

Official Designation Date


NUMBERED BOX) AT THE BACK BEFORE ACCOMLISHING THIS FORM

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