Pmrf Revised

PMRF

Republic of the Philippines

PHILIPPINE HEALTH INSURANCE CORPORATION

PHILHEALTH MEMBER REGISTRATION FORM

Citystate Centre Building, 709 Shaw Boulevard, Pasig City
Healthline 441-7444 www.philhealth.gov.ph

(October 2013)
PhilHealth Identification Number (PIN)

IMPORTANT REMINDERS:
1. Your PhilHealth Identification Number (PIN) is your unique and permanent number.
2. The issuance of the PIN does not automatically qualify you or your dependents to be entitled to NHIP benefits.
3. Always use your PIN in all transactions with PhilHealth.

PURPOSE:

Please carefully read instructions at the back before accomplishing this form.
1. MEMBER INFORMATION
Last Name

FOR ENROLLMENT

FOR UPDATING

First Name

Name Extension (JR/SR/III)

Middle Name

If Married Female, please write FULL MAIDEN NAME:
Last Name
First Name

Name Extension (JR/SR/III)

Middle Name

Date of Birth (mm-dd-yyyy) Place of Birth (City/Municipality/Province)

Permanent Address
Unit/Room No./Floor

Building Name

Barangay

Sex
Male
Female

Civil Status
Single
Widow(er)
Married
Legally Separated

Lot/Block/House/Bldg. No.

City/Municipality

Contact Information
Landline Number (Area Code + Tel. No.)

Nationality

Tax Identification No.(TIN)

Street

Province

Subdivision/Village

Country

Mobile Number

Zip Code

E-mail Address

2. DECLARATION OF DEPENDENTS (Use separate sheet if necessary)
2.1 Legal Spouse
PhilHealth Identification
Number (PIN)

Last Name

First Name

Name Extension
(JR/SR/III)

Middle Name

Date of Birth mm-dd-yyyy Sex
M/F

Date of Birth mm-dd-yyyy Sex
M/F

2.2 Children below 21 years old (unmarried & unemployed) and/or Children 21 years old and above with permanent disability
Last Name

First Name

Name Extension
(JR/SR/III)

Middle Name

Mark √ if with
Disability

PhilHealth Identification
Number (PIN)

Father’s Last Name

Father’s First Name

Name Extension
(JR/SR/III)

Father’s Middle Name

Mark √ if with
Permanent
Disability

Date of Birth
(mm-dd-yyyy)

PhilHealth