Get Philhealth Annex A

This guide provides clear instructions on how to successfully fill out the Philhealth Annex A form online. It will help you understand each section and field, ensuring a smooth completion process.

Follow the steps to fill out the Philhealth Annex A online

1. Press the ‘Get Form’ button to obtain the Philhealth Annex A form and open it in your preferred editing tool.
2. Provide the case number in the designated field at the top of the form.
3. Fill in the health care institution (HCI) details, including the name and address of the HCI.
4. Enter the patient's information by filling out their last name, first name, middle name, and suffix, along with their PhilHealth ID number.
5. If the patient is a dependent, complete the member's information section by entering the last name, first name, middle name, suffix, and PhilHealth ID number of the member.
6. Indicate whether the criteria for pre-authorization have been fulfilled by checking 'Yes' or 'No.' If 'No,' specify the reasons in the provided space.
7. Complete the pre-authorization checklist by placing a check mark where applicable, following the guidelines for the patient's eligibility based on age and diagnostic criteria.
8. Document the necessary diagnostics by entering the date performed, as well as the specified CBC and CSF cell count results.
9. Have the attending physician certify the form by providing their printed name and signature, along with PhilHealth accreditation number.
10. Once all fields are complete, review your entries for accuracy, then save the form, download, print, or share it according to your needs.

Start filling out your documents online today!