PhilHealth Registration Form 2023-2024 | PDF Download
We are pleased to inform you about PhilHealth Registration Form 2023-2024 | PDF Download
PhilHealth Registration Form also known as Philhealth Member Registration Form PMRF is used when applying for membership or registering with Philhealth.
It is also used when updating the member data for changes such as in civil status, membership category, list of dependents, and others.
For first time registration with Philhealth as employed member, the PMRF will have to be accompanied by the ER2 (Report of Employee-Members) form which has to be filled out and signed by the employer.
Philhealth Registration Form Download
Instruction on how to fill out the Philhealth Form
1.All information should be written in UPPER CASE/CAPITAL LETTERS. If the information is not applicable,write “N/A.”
2.All fields are mandatory unless indicated as optional. By affixing your signature, you certify the truthfulness and accuracy of all information provided.
3.A properly accomplished PMRF shall be accompanied by a valid proof of identity for first-time registrants, and supporting documents to establish a relationship between the member and dependent/s for updating or request for amendment.
4.On the PURPOSE, check the appropriate box if for registration or forUpdating/Amendment of information.
5.Indicate preferred KonSulTa provider near the place of work or residence.
6.For PERSONAL DETAILS, all name entries should follow the format given below. Check the appropriate box if the registrant has no middle name and/or with a single name (mononym).
LAST NAME SANTOS
FIRST NAME JUAN ANDRES
NAME EXTENSION(Jr./Sr./III) III
MIDDLE NAME DELA CRUZ
7.Indicate registrant’s/member’s name as it appears in the birth certificate.
8.The full mother’s maiden name of registrant/member must be indicated as it appears in the birth certificate.
9.Indicate the full name of spouse if the registrant/member is married.
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10.Indicate the complete permanent and mailing addresses and contact numbers.
11.For updating/amendment, check the appropriate box to be updated/amended and indicate the correct data.
12.For MEMBER TYPE, check the appropriate box which best describes your current membership status.1
3.For Direct Contributors, except employed, sea-based migrant workers, and lifetime members, indicate the profession, monthly income and proof of income to be submitted.
14.For Self-earning individuals, Kasambahays and Family Drivers, indicate the actual monthly income in the space provided.
15.In declaring dependents, provide the full name of the living spouse, children below 21 years old, and parents who are 60 years old and above totally dependent on the member.
16.Dependents with a disability shall be registered as principal members in accordance with Republic Act 11228 on mandatory PhilHealth coverage for all persons with disability (PWD).
17.The registrant must affix his/her signature over the printed name (or right thumbmark if unable to write) and indicate the date when the PMRF was signed.
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