Documenti di Didattica
Documenti di Professioni
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Date
Membership/Collection Section
PHILIPPINE HEALTH INSURANCE CORPORATION
Sir/Madam:
I,_________________________________________, born on _____________________ with an assigned
Name of Member (Last name, First name, Middle name)
and a
paying member of the National Health Insurance Program would like to request for the issuance of:
PhilHealth Identification Card (PIC)
Member Data Record (MDR)
Contribution history
Certificate of Premium Payment (CPP)
Certification for lost payment receipt
for the purpose of:
Replacement of Lost PhilHealth ID or PNC (with attached Affidavit of Loss)
Replacement of Damaged PhilHealth ID or PNC (attached damaged card)
Availing PhilHealth benefits as required by the hospital
Others:
_____________________________
(Signature over Printed Name)
Address:
_______________________________________________________________
Lot/Block no./ Street name
Contact No:
Barangay
Municipality/City
___________________________
Province