PhilHealth Annex D: Member Empowerment (ME Form)
Fill PhilHealth Annex D: Member Empowerment (ME Form) 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, PATIENT (Last name, First name, Middle name, Suffix), PHILHEALTH ID NUMBER OF PATIENT, MEMBER (if patient is a dependent) (Last name, First name, Middle name, Suffix), PHILHEALTH ID NUMBER OF MEMBER, PERMANENT ADDRESS, Birthday (mm/dd/yyyy), Telephone Number, Mobile Number, Email Address, Employed private, Employed government.
The form is the agency's own, from philhealth.gov.ph (checked 2026-10-14): the PDF you download is that form with your values printed in its boxes.
The free clean PDF is that pack’s shortest form. A later form in the same pack needs the Starter plan (₱499) or above. Preview, check, and verify stay free. Not affiliated with BIR, SSS, PhilHealth, Pag-IBIG or any government agency.