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Deactivation Request

This document contains a form from the Philippine Health Insurance Corporation for requesting deactivation of a PhilHealth membership or transferring dependents. The form requests the member's name, PhilHealth number, and reason for either requesting deactivation of their membership or transferring their declared dependents to a spouse, and includes signature lines for the inactive or active member.

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griever666127
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3K views1 page

Deactivation Request

This document contains a form from the Philippine Health Insurance Corporation for requesting deactivation of a PhilHealth membership or transferring dependents. The form requests the member's name, PhilHealth number, and reason for either requesting deactivation of their membership or transferring their declared dependents to a spouse, and includes signature lines for the inactive or active member.

Uploaded by

griever666127
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Republic of the Philippines

PHILIPPINE HEALTH INSURANCE CORPORATION


8007 Pioneer St., Kapitolyo, Pasig City
Call Call Center: (02) 8441-7442 | Trunkline: (02) 8441-7444
www.philhealth.gov.ph

DEACTIVATION REQUEST

Date: _____________

Deactivation

I, ___________________________________, with PhilHealth Number ____________, would like to request


your good office to please deactivate my said membership due to ______________________________
(REASON)

Transfer of Dependent

I, ___________________________________, with PhilHealth Number ____________, would like to request


your good office to transfer my declared dependent(s) namely ______________________________________
to my spouse due to ___________________________________________________
(REASON)

Truly yours,

________________________________________ ______________________________________________
(Signature over printed name-INACTIVE Member (Signature over printed name – ACTIVE Member)

Republic of the Philippines


PHILIPPINE HEALTH INSURANCE CORPORATION
8007 Pioneer St., Kapitolyo, Pasig City
Call Call Center: (02) 8441-7442 | Trunkline: (02) 8441-7444
www.philhealth.gov.ph

DEACTIVATION REQUEST

Date: _____________

Deactivation

I, ___________________________________, with PhilHealth Number ____________, would like to request


your good office to please deactivate my said membership due to ______________________________
(REASON)

Transfer of Dependent

I, ___________________________________, with PhilHealth Number ____________, would like to request


your good office to transfer my declared dependent(s) namely ______________________________________
to my spouse due to ___________________________________________________
(REASON)

Truly yours,

________________________________________ ______________________________________________
(Signature over printed name-INACTIVE Member (Signature over printed name – ACTIVE Member)

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