This form may be reproduced and is NOT FOR SALE

CF4
(Claim Form 4)
August 2018
February 2020
Series #
IMPORTANT REMINDERS:
PLEASE FILL OUT APPROPRIATE FIELDS. WRITE IN CAPITAL LETTERS AND CHECK THE APPROPRIATE BOXES.
This form, together with other supporting documents, should be filed within sixty (60) calendar days from date of discharge.
All information, fields and tick boxes in this form are necessary. Claim forms with incomplete information shall not be processed.
FALSE / INCORRECT INFORMATION OR MISREPRESENTATION SHALL BE SUBJECT TO CRIMINAL, CIVIL OR ADMINISTRATIVE LIABILITIES.
I. HEALTH CARE INSTITUTION (HCI) INFORMATION
1. Name of HCI 2. Accreditation Number
{HIS:fac}
3. Address of HCI
{FacilityAddress}
Bldg No. and Name/Lot/Block Street/Subdivision/Village Barangay/City/Municipality Province Zip Code

II. PATIENT’S DATA

1. Name of Patient 2. PIN
{DEM:lname} {DEM:fname} {DEM:mname}
Last Name First Name Middle Name 3. Age
5. Chief Complaint {PatientAge}
4. Sex Male Female
{ChiefComplaint}
6. Admitting Diagnosis 7. Discharge Diagnosis 8. a. 1st Case Rate Code
{LBFCF4:wimp} {LBFCF4:pods} {LBFoptech:rvs}
8. b. 2nd Case Rate Code

9. a. Date Admitted: 2 0 2 4 9. b. Time Admitted:

- - : 3 9 AM PM
month day year hour min
10. a. Date Discharged: 10. b. Time Discharged: 1 2
- - 2 0 2 4 0 3 : AM PM
month day year hour min
III. REASON FOR ADMISSION
1. History of Present Illness:
{HIS:HPI}

2.a. Pertinent Past Medical History:

{HIS:Phx}

2.b. OB/GYN History

G P ( - - - ) LMP: NA

3. Pertinent Signs and Symptoms on Admission (tick applicable box/es):

Altered mental sensorium Diarrhea Hematemesis Palpitations

Abdominal cramp/pain Dizziness Hematuria Seizures

Anorexia Dysphagia Hemoptysis Skin rashes

Bleeding gums Dyspnea Irritability Stool, bloody/black tarry/mucoid

Body weakness Dysuria Jaundice Sweating

Blurring of vision Epistaxis Lower extremity edema Urgency

Chest pain/discomfort Fever Myalgia Vomiting

Constipation Frequency of urination Orthopnea Weight loss

head Others
Cough Headache Pain, ______________(site)

4. Referred from another health care institution (HCI): No Yes, Specify Reason

Name of Originating HCI

5. Physical Examination on Admission (Pertinent Findings per System)

General Survey Awake and alert Altered sensorium: drowsy

Vital Signs: BP: 130/80 HR: 104 RR: 24 Temp: 37.6
HEENT: Essentially normal Abnormal pupillary reaction Cervical lymphadenopathy Dry mucous membrane

Icteric sclerae Pale conjunctivae Sunken eyeballs Sunken fontanelle

Others: