Maternity Care Package
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PHILHEALTH
MATERNITY CARE
PACKAGE
CLAIM FORM 4
April 2003
NOTE: THIS FORM TOGETHER WITH CLAIM FORM 1 SHOULD BE FILED WITH PHILHEALTH WITHIN 60 CALENDAR DAYS FROM DATE OF DISCHARGE.
PART I - FACILITY DATA AND CHARGES ( Facility to Fill in All Items )
1. PhilHealth Accreditation No.
2. Accreditation Category
Secondary
Tertiary
Primary
Non-Hospital Facilities (Lying-in clinics,Midwife-managed clinics,
Birthing Homes,Ambulatory Surgical Clinics)
3. Name of Facility
4. Address of Facility
No., Street
Barangay
Municipality/City
Province
Zip Code
5. Name of Member
5. Name of Member and Identification
Last Name
First Name
Middle Name
PhilHealth
Identification No.
6. Address of Member
No., Street
Barangay
Municipality/City
Province
Zip Code
7. Name of Patient
8. Age
9. Admission Diagnosis
Last Name
First Name
Middle Name
10.
Confinement Period
m m d d y y y y
m m d d y y y y
a. Date Admitted
b. Date Discharged
c. Total No.of Days
m m d d y y y y
d. Date of Death
(If Applicable)
11.
Facility Services
ACTUAL FACILITY
BENEFIT CLAIM
CHARGES
FACILITY
PATIENT
REDUCTION CODE
TOTAL
Medicines & Supplies bought & laboratory
performed outside facility during confinement period
12. CERTIFICATION of FACILITY: I certify that the services rendered are duly recorded in the patient's chart and that the information
given in this form are true and correct.
Signature Over Printed Name of Authorized Representative
Date Signed
Official Capacity
PART II - PROFESSIONAL DATA AND CHARGES (Provider/s to Fill in Respective Portions )
13. Complete Final Diagnosis
:
14. ICD-10 Code
FOR PHILHEALTH USE
RVS Code
15. Name of Provider
Signature & Date Signed
Illness Code
16.PHIC Accreditation No.
-
-
Reduction Code
17. BIR/TIN No.
18. Services Performed
Benefit Claim
19.
Actual
Provider
Patient
Professional Charges
P
P
P
NOTE: ANYONE WHO SUPPLIES FALSE OR INCORRECT INFORMATION REQUESTED BY THIS OR A RELATED FORM OR COMMITS MISREPRESENTATION SHALL BE
SUBJECT TO CRIMINAL, CIVIL OR ADMINISTRATIVE PROSECUTION UNDER THE LAW. ALL DATA REQUIRED ON THIS FORM ARE NECESSARY FOR ADJUDICATION OF
THE CLAIM. PHILHEALTH WILL NOT ADJUDICATE ANY CLAIM WHERE FORMS ARE NOT PROPERLY OR COMPLETELY ACCOMPLISHED.
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