Republic of the Philippines

PHILIPPINE HEALTH INSURANCE CORPORATION PMRF

Citystate Centre Building, 709 Shaw Boulevard,Pasig City PHILHEALTH MEMBER REGISTRATION FORM
Call Center: 8441-7442/ Trunkline: 8441-7444
www.philhealth.gov.ph
UHC v.1 October 2019

NOTE/INSTRUCTION:
PHILHEALTH IDENTIFICATION NUMBER (PIN)
1. Write in UPPER CASE/CAPITAL LETTERS. The member must fill-out all
required information and write “N.A.” if the information is not applicable.
2. For Updating/Amendment check the appropriate box and provide details to
be accomplished and submit corresponding supporting documents. PURPOSE:
3. Always use your PIN in all transactions with PhilHealth.
4. Your PhilHealth Identification Number (PIN) is your unique and permanent REGISTRATION UPDATING/AMENDMENT
number.

I. PERSONAL DETAILS
NAME NO
MIDDLE MONONYM
LAST NAME FIRST NAME EXTENSION MIDDLE NAME NAME
(Jr./Sr./III)
(Check if applicable only)

MEMBER
MOTHER’s
MAIDEN NAME

SPOUSE
(If Married)
DATE OF BIRTH PLACE OF BIRTH (City/Municipality/Province/Country)
(Please indicate country if born outside the Philippines) PHILSYS ID NUMBER (Optional)

m m d d y y y y
SEX CIVIL STATUS CITIZENSHIP
TAX PAYER IDENTIFICATION NUMBER (TIN) (Optional)
Male Single Annulled FILIPINO DUAL CITIZEN
Female Married Widow/er
NON-FILIPINO
Legally Separated
II. ADDRESS and CONTACT DETAILS
PERMANENT HOME ADDRESS (Indicate country code if abroad)
Unit/Room No./Floor Building Name Lot/Block/Phase/House Number Street Name COUNTRY + AREA CODE + TELEPHONE NUMBER
Home
Subdivision Barangay Municipality/City Province/State/Country (If abroad) ZIP Code

Mobile Number (Required)

MAILING ADDRESS SAME AS ABOVE

Unit/Room No./Floor Building Name Lot/Block/Phase/House Number Street Name Business (Direct Line)

Subdivision Barangay Municipality/City Province/State/Country (If abroad) ZIP Code E-mail Address (Required for OFW)

III. UPDATING/AMENDMENT
FROM TO
Change/Correction of Name of Registrant or
Dependent (Last Name, First Name, Name Extension (Jr./
Sr./III) Middle Name)

Correction of Date of Birth

Correction of Sex
Change of Civil Status
Updating of Personal Information/Address/
Telephone Number/Mobile Number/e-mail
Address
IV. MEMBER TYPE
DIRECT CONTRIBUTOR INDIRECT CONTRIBUTOR
Employed Private Migrant Worker Indigent
Employed Government Land-Based 4Ps/MCCT
Self-Earning Individual Sea-Based Person With Disability (PWD)
Individual Filipinos with Dual Citizenship/ Living Abroad Senior Citizen
Group Enrollment Foreign National Survivorship
_________________
Professional Practitioner PRA SRRV No./ACR I-Card No. _____________ Killed In Action (KIA)
Kasambahay/Family Driver Lifetime Member Wounded In Action (WIA)
PROOF OF INCOME: PROFESSION: MONTHLY INCOME: Sangguniang Kabataan Official
(Except Employed and Lifetime)
Point of Service/Financially Incapable
Others: ___________________
Continue at the back
This form may be reproduced and is not for sale Page 1 of 1 of Annex A
 III. DECLARATION OF DEPENDENTS (Use additional form if necessary)
DATE OF
NO MIDDLE Check if
NAME MONONYM BIRTH with
LAST NAME FIRST NAME EXTENSION
(Jr./Sr./III)
MIDDLE NAME NAME RELATIONSHIP (mm-dd-yyyy) CITIZENSHIP
Permanent
Disability
(Check if applicable only)

To be filled-out by the Guardian (For registration of Minor & Orphan’s Enrollees):

By virtue of a Judicial Order/affidavit of Guardianship, I _____________________________________________________________

(Complete Name)

born on _______________ and residing at _______________________________________________________________________

(mm/dd/yyyy) (Permanent Address)

will take full responsibility for the member’s data indicated herein as well as decisions relating to the member’s PhilHealth interest.

__________________________________________________ ____________________________________________
PhilHealth Identification Number (PIN) of Guardian Guardian’s Signature over printed name

Under the penalty of the law, I hereby attest that the

information provided, including the documents I have FOR PHILHEALTH USE ONLY
attached to this form, are true and accurate to the best of
my knowledge. I trust that the data shall remain
confidential. Thus, I give my consent that the data
provided herein be secured and accessed for subsequent RECEIVED BY:
validation, verification and for other data sharing purposes Please affix right thumbmark if
consistent with Data Privacy Act of 2012 under the unable to write
following circumstances. Name: ________________________________
· As necessary for the proper execution of processes
related to the legitimate and declared purpose;
· The use or disclosure is reasonably necessary, PRO/LHIO/Branch: ______________________
required or authorized by or under the law; and
· Adequate security measures are employed to protect
my information. Date & Time: ___________________________

_____________________________________________ __________________
Member’s signature over Printed Name Date

REMINDER:

MEMBER/REGISTRANT – Submit properly accomplished PMRF and attach any valid proof of identity bearing the following information
(LAST NAME, FIRST NAME, NAME EXTENSION, MIDDLE NAME, CIVIL STATUS, SEX).

– For declaration of dependent/s submit any valid proof of dependency attesting the relationship of the
member to the declared dependent/s).