PhilHealth Annex C.1: Pre -authorization Checklist and Request Form for Wheelchairs
Fill PhilHealth Annex C.1: Pre -authorization Checklist and Request Form for Wheelchairs online and download the official form as a PDF, ready to print. Every input is mapped to its printed box, so IDs, dates and amounts land digit by digit in the right cells, and a value the form cannot hold is refused with the reason instead of being printed wrong.
What you will need: Case No, 1. Last Name, First Name, Suffix, Middle Name, 2. PhilHealth ID Number, Same as patient, General Criteria, Not Applicable, (mm/ yyyy) , Inability to walk <400 meters or endure 10 minutes of continuous walking, Place a checkmark () on the appropriate type of Assistive Mobility Device, Certified correct by, PhilHealth Accreditation No, Date signed (mm/dd/yyyy).
Free to try: 5 forms a day without an account; a free account gets 14 days of clean PDFs, then 25 a month. Not affiliated with BIR, SSS, PhilHealth, Pag-IBIG or any government agency.