PhilHealth Annex E.6: Checklist of Requirements for Reimbursement – Surveillance
Fill PhilHealth Annex E.6: Checklist of Requirements for Reimbursement – Surveillance 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, Middle Name, Suffix, 2. PhilHealth ID Number, 1. Checklist of Requirements for Reimbursement – Surveillance, 3. Photocopy of approved Pre-authorization Checklist and Request (Annex A.2), 4. Photocopy of Member Empowerment Form (Annex B), 7. Checklist of Mandatory and Other Services (Annex C.6), DATE COMPLETED (mm/dd/yyyy), DATE FILED (mm/dd/yyyy), Certified correct by, Conforme by, PhilHealth Accreditation No.
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