E Konsulta Form

PhilHealth Konsulta Registration Form PhilHealth Konsulta Registration Form PhilHealth Konsulta Registration Form

To be filled-out by the Beneficiary To be filled-out by the Beneficiary To be filled-out by the Beneficiary

Name: _____________________________________ Name: _____________________________________ Name: _____________________________________
PIN: _______________________________________ PIN: _______________________________________ PIN: _______________________________________
Member: ___ Dependent: ____ (please check) Member: ___ Dependent: ____ (please check) Member: ___ Dependent: ____ (please check)
Contact No.: _______________________________ Contact No.: _______________________________ Contact No.: _______________________________
Email Address (if applicable): __________________ Email Address (if applicable): __________________ Email Address (if applicable): __________________
Preferred PhilHealth Konsulta Facility and Address Preferred PhilHealth Konsulta Facility and Address Preferred PhilHealth Konsulta Facility and Address
(Municipality/Town/City/Province): (Municipality/Town/City/Province): (Municipality/Town/City/Province):
1st Choice: OLUTANGA MUNICIPAL HOSPITAL______ 1st Choice: OLUTANGA MUNICIPAL HOSPITAL______ 1st Choice: OLUTANGA MUNICIPAL HOSPITAL______
2nd Choice: __________________________________ 2nd Choice: __________________________________ 2nd Choice: __________________________________
3rd Choice: __________________________________ 3rd Choice: __________________________________ 3rd Choice: __________________________________

_______________________________ _______________________________ _______________________________

Signature over Printed Name Signature over Printed Name Signature over Printed Name
PhilHealth’s Copy PhilHealth’s Copy PhilHealth’s Copy
------------------------------------------------------------------------- ------------------------------------------------------------------------- -------------------------------------------------------------------------
PhilHealth Konsulta Registration Confirmation PhilHealth Konsulta Registration Confirmation PhilHealth Konsulta Registration Confirmation
SlipTo be filled-out by the Authorized SlipTo be filled-out by the Authorized SlipTo be filled-out by the Authorized
personnel personnel personnel
Registration No.: ________________________________ Registration No.: ________________________________ Registration No.: ________________________________
Date Registered: ________________________________ Date Registered: ________________________________ Date Registered: ________________________________
Name: ________________________________________ Name: ________________________________________ Name: ________________________________________
PIN: __________________________________________ PIN: __________________________________________ PIN: __________________________________________
PhilHealth Konsulta Facility: OLUTANGA MUNICIPAL HOSPITAL PhilHealth Konsulta Facility: OLUTANGA MUNICIPAL HOSPITAL PhilHealth Konsulta Facility: OLUTANGA MUNICIPAL HOSPITAL
PhilHealth Konsulta Facility Address: Bateria, Olutanga, Zamboanga Sibugay PhilHealth Konsulta Facility Address: Bateria, Olutanga, Zamboanga Sibugay PhilHealth Konsulta Facility Address: Bateria, Olutanga, Zamboanga Sibugay
____________________________________ ____________________________________ ____________________________________

Signature over Printed Name of Authorized Personnel Signature over Printed Name of Authorized Personnel Signature over Printed Name of Authorized Personnel
Beneficiary’s Copy Beneficiary’s Copy Beneficiary’s Copy

Instructions: Instructions: Instructions:
1. All information should be written in UPPER CASE/CAPITAL 1. All information should be written in UPPER CASE/CAPITAL 1. All information should be written in UPPER
LETTERS. LETTERS. CASE/CAPITAL LETTERS.
2. All fields are mandatory. 2. All fields are mandatory. 2. All fields are mandatory.
3. If the beneficiary is dependent, use the dependent PIN. 3. If the beneficiary is dependent, use the dependent PIN.
3. If the beneficiary is dependent, use the dependent PIN.
4. If the beneficiary is below 21 years old, the signatory should 4. If the beneficiary is below 21 years old, the signatory
4. If the beneficiary is below 21 years old, the signatory
be the parent/guardian. should be the parent/guardian.
should be the parent/guardian.

E Konsulta Form

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E Konsulta Form

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PhilHealth Konsulta Registration Form PhilHealth Konsulta Registration Form PhilHealth Konsulta Registration Form

To be filled-out by the Beneficiary To be filled-out by the Beneficiary To be filled-out by the Beneficiary

_______________ _ _________________

Beneficiary’s Copy Beneficiary’s Copy Beneficiary’s Copy

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