PhilHealth Annex A.1.: Pre-authorization Checklist and Request Form For Kidney Transplant Recipient
Fill PhilHealth Annex A.1.: Pre-authorization Checklist and Request Form For Kidney Transplant Recipient 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, Last Name, First Name, Middle Name, Suffix, PhilHealth ID Number, Same as above, History of Kidney Transplantation, Living Organ Donor, Name of the Kidney Transplant Facility, Address of the Kidney Transplant Facility, Date of kidney transplantation (mm/dd/yyyy), 19 year old and above, Medical abstract translated into an English version, Filipino Dual Citizenship Certificate (as applicable).
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.