PMRF

PhilHealth Your Partner in Health

1. Your PhilHealth Identification Number (PIN) is your unique and permanent number. 2. Always use your PIN in all transactions with PhilHealth. 3. For Updating/Amendment check the appropriate box and provide details to be accomplished and submit corresponding supporting documents. 4. Please read instructions at the back before filling-out this form.

I. PERSONAL DETAILS FIRST NAME

Single Married Legally Separated

II. ADDRESS and CONTACT DETAILS

Unit/Room No./Floor Building NameLot/Block/Phase/House Number

Municipality/City Province/State/Country (If abroad)

Municipality/CityProvince/State/Country (If abroad)

E-mail Address (Required for OFW)

III. DECLARATION OF DEPENDENTS

(Use additional form if necessary)

Check if with Permanent Disability

Employed Private Employed Government

Kasambahay Migrant Worker Land-Based Lifetime Member

Listahanan 4Ps/MCCT Senior Citizen

Filipinos with Dual Citizenship Living Abroad

LGU-sponsored NGA-sponsored Private-sponsored Person with Disability

Sole Proprietor Group Enrollment Scheme

Foreign National PRA SRRV No. ACR I-Card No.

PROFESSION: (Except Employed, Lifetime Members andMONTHLY INCOME: PROOF OF INCOME: Sea-based Migrant Worker)

Point of Service (POS) Financially Incapable

This form may be reproduced and is notfor sale

Please check: Change/Correction of Name (Last Name, First Name, Name Extension (Jr./Sr./III) Middle Name) Correction of Date of Birth

Change of Civil Status Updating of Personal Information/Address/ Telephone Number/Mobile Number/e-mail Address

Under penalty of law, I hereby attest that the information provided, including the documentsI 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.

1. All information should be written in UPPER CASE/CAPITAL LETTERS. If the information is not applicable, write "N/A." 2. All fields are mandatory unless indicated as optional. By affixing your signature, you certify the truthfulness and accuracy of all information provided. 3.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. 4.On the PURPOSE, check the appropriate box if for Registration or for Updating/Amendment of information. 5. Indicate preferred KonSulTa provider near the place of work or residence. 6.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

7.Indicate registrant's/member's name as it appears in the birth certificate. 8.The full mother's maiden name of registrant/member must be indicated as it appears in the birth certificate.

9. Indicate the full name of spouse if registrant/member is married. 10. Indicate the complete permanent and mailing addresses and contact numbers. 11. For updating/amendment, check the appropriate box to be updated/amended and indicate the correct data. 12. For MEMBER TYPE, check the appropriate box which best describes your current membership status. 13. For Direct Contributors, except employed, sea-based migrant workers and lifetime members, indicate the profession, monthly income and proof of income to be submitted. 14. For Self-earning individuals, Kasambahays and Family Drivers, indicate the actual monthly income in the space provided. 15. 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. 16. 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 17. 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.