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PhilHealth Online Access Form Guide

This document is a PhilHealth Online Access Form used to register accredited health care providers for online access. It collects information such as the name and address of the provider, contact details of the user, and requires signatures from the user and approvers at PhilHealth to authorize the online access and provide login credentials. Upon completion, the health care provider's medical director must also confirm the registration.

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1K views1 page

PhilHealth Online Access Form Guide

This document is a PhilHealth Online Access Form used to register accredited health care providers for online access. It collects information such as the name and address of the provider, contact details of the user, and requires signatures from the user and approvers at PhilHealth to authorize the online access and provide login credentials. Upon completion, the health care provider's medical director must also confirm the registration.

Uploaded by

Lyy
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
  • Philhealth Online Access Form

ANNEX A

PHILHEALTH ONLINE ACCESS FORM NO. Registration Date


(POAF) Form No. 002

Name of Accredited Institutional Health Care Provider PhilHealth Accreditation Number

Business Address

User Profile
Complete Name Signature

Position Email address Mobile No.

Approved by: Date Signed

To be filled-out by PhilHealth
Installation Date Regional / Branch Office Email address

Username Password

Processed by Signature Date Processed

Approved by Signature Date Signed

Institutional Confirmation
Confirmed by: Medical Director/Administrator/Authorized Representative Date Confirmed

ANNEX A PHILHEALTH ONLINE ACCESS FORM (POAF) Form No. 002 NO. Registration Date Name of Accredited Institutio

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