PhilHealth Annex " E.4 – Visual Disability ”
Fill PhilHealth Annex " E.4 – Visual Disability ” 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 E.4), 2. PhilHealth Benefit Eligibility Form or equivalent or Claim Form1, 3. PhilHealth Claim Form2 (CF2), 4. Checklist of Mandatory Service (Annex C.3), DATE COMPLETED, DATE FILED.
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