PhilHealth Annex " E1 – Hearing Impairment ”
Fill PhilHealth Annex " E1 – Hearing Impairment ” 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, HEALTH CARE INSTITUTION (HCI), ADDRESS OF HCI, PATIENT (Last name, First name, Middle name, Suffix), PHILHEALTH ID NUMBER OF PATIENT, PHILHEALTH ID NUMBER OF MEMBER, 1. Checklist of Requirements for Reimbursement (Annex E1), 2. Photocopy of approved Pre–Authorization Checklist & Request (Annex A), 4. Completed PhilHealth Claim Form (CF1) or PhilHealth Benefit Eligibility, 5. PhilHealth Claim Form 2, 6. Checklist of Mandatory Service for Hearing Impairment (Annex C1), 8. Photocopy of the ABR waveform tracing or applicable hearing test result.
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