REMINDERS:
1. Your PhilHealth Identification Number (PIN) is your unique and permanent number.
2. Always use your PIN in all transactions with PhileHealth.
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
PMRF
PHILHEALTH MEMBER REGISTRATION FORM
UCH v.1 January 2020
PHILHEALTH IDENTIFICATION NUMBER
PURPOSE:
REGISTRATION
UPDATING/AMENDMENT
Preferred KonSul Ta Provider
I. PERSONAL DETAILS
LAST NAME
FIRST NAME
NAME EXTENSION
MIDDLE NAME
NO MIDDLE NAME
MONONYM
MEMBER
Extension
JR
SR
II
III
IV
V
VI
MOTHER's MAIDEN NAME
Extension
JR
SR
II
III
IV
V
VI
SPOUSE
(If Married)
Extension
JR
SR
II
III
IV
V
VI
DATE OF BIRTH
SEX
MALE
FEMALE
CIVIL STATUS
Single
Annulled
Married
Widow/er
Legally Separated
PLACE OF BIRTH
(City/Municipality/Country)
(Please indicate country if born outside the Philippines)
CITIZENSHIP
FILIPINO
FOREIGN NATIONAL
DUAL CITIZEN
PHILSYS ID NUMBER (Optional)
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
Barangay
Municipality/City
Province/State/Country (if Abroad)
ZIP Code
MAILING ADDRESS
SAME AS ABOVE
Unit/Room No./Floor
Building Name
Lot/Block/Phase/House Number
Street Name
Subdivision
Barangay
Municipality/City
Province/State/Country (if Abroad)
ZIP Code
Home Phone Number:
(COUNTRY CODE + AREA CODE + TELEPHONE NUMBER)
Mobile Number (required)
Business (Direct Line)
E-mail Address (Required for OFW)
III. DECLARATION OF DEPENDENTS
LAST NAME
FIRST NAME
NAME EXTENSION
MIDDLE NAME
RELATIONSHIP
DATE OF BIRTH
CITIZENSHIP
NO MIDDLE NAME
MONONYM
CHECK IF WITH PERMANENT DISABILITY
Extension
JR
SR
II
III
IV
V
VI
Extension
JR
SR
II
III
IV
V
VI
Extension
JR
SR
II
III
IV
V
VI
Extension
JR
SR
II
III
IV
V
VI
IV. MEMBER TYPE
DIRECT CONTRIBUTOR
Employed Private
Kasambahay
Family Driver
Employed Government
Migrant Worker
Professional Practitioner
Land-Based
Sea-Based
Self-earning Individual
Lifetime Member
Individual
Filipinos with Dual Citizenship / Living Abroad
Sole Proprietor
Foreign National
Group Enrollment Scheme
PRA SSRV No.:
ACR I-Card No.:
PROFESSION:
(Except Employed, Lifetime Members and Sea-Based Migrant Worker)
MONTHLY INCOMME
PROOF OF INCOME
INDIRECT
CONTRIBUTOR
Listahanan
LGU-sponsored
4Ps/MCCT
NGA-sponsored
Senior Citizen
Private-sponsored
PAMANA
Person with Disability
KIA/KIPO
Bangsamoro/Normalization
For Philhealth Use only:
Point of Service (POS) Financially Incapable
Financially Incapable
V. UPDATING
Please Check:
FROM
TO
Change/correction of name
(Last Name, First Name, Name Extension (Jr./Sr/III), Middle Name)
Correction of Date of Birth
Correction of Sex
Select Sex
Male
Female
Select Sex
Male
Female
Change of Civil Status
Select Civil Status
Single
Married
Widowed
Legally Separated
Select Civil Status
Single
Married
Widowed
Legally Separated
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 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 process related to the legitimate and declared purposes;
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
Member's Name
Date
For Philhealth Use only:
RECEIVED BY:
Full Name
PRO./LHIO/Branch
Date and Time:
Attach File
SUBMIT
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