PMRF

PHILHEALTH MEMBER REGISTRATION FORM

UHC v.1 January 2020
REMINDERS:
PHILHEALTH IDENTIFICATION NUMBER (PIN)
1. Your PhilHealth Identification Number (PIN) is your unique and
permanent PURPOSE:
number.
2. Always use your PIN in all transactions with REGISTRATION UPDATING/AMENDMENT
PhilHealth.
3. For Updating/Amendment check the appropriate box and provide details to Preferred KonSulTa Provider
be accomplished and submit corresponding supporting documents.
4. Please read instructions at the back before filling-out this form.

I. PERSONAL DETAILS
NAME NO
LAST NAME FIRST NAME EXTENSIO MIDDLE NAME MIDDLE
NAME
MONONYM

N
(Jr./Sr./III) (Check if app licable only)

MEMBER
MOTHER’s
MAIDEN NAME
SPOUSE
(If Married)

DATE OF BIRTH PLACE OF BIRTH

(City/Municipality/Province/Country) (Please indicate country PHILSYS ID NUMBER (Optional)
if born outside the Philippines)

m m d d y y y y
SEX CIVIL STATUS CITIZENSHIP TAX PAYER IDENTIFICATION NUMBER (TIN) (Optional)
Male Single Annulled FILIPINO FOREIGN NATIONAL
Female Married
Widow/er DUAL CITIZEN
Legally Separated
II. ADDRESS and CONTACT DETAILS
PERMANENT HOME ADDRESS Home Phone Number
Unit/Room No./Floor Building Name Lot/Block/Phase/House Number Street
Name

(COUNTRY CODE + AREA CODE + TELEPHONE NUM BER)

Subdivision Barangay Municipality/City Province/State/Country (If abroad) ZIP
Code Mobile Number (Required)

MAILING SAME AS ABOVE

ADDRESS
Unit/Room No./Floor Building Name Lot/Block/Phase/House Number Street Name Business (Direct Line)

Subdivision Barangay Municipality/City Province/State/Country (If abroad) ZIP E-mail Address (Required for OFW)
Code

III. DECLARATION OF DEPENDENTS (Use additional form if necessary)

DATE NO
Check if
NAME MIDDLE MONONYM
LAST NAME FIRST NAME EXTENSION MIDDLE NAME RELATIONSHI OF
BIRTH
CITIZENSHI NAME
with
Permanent
(Jr./Sr./III) P P Disability
(mm-dd-
yyyy)
(Check if app licable only)

IV. MEMBER TYPE

DIRECT CONTRIBUTOR INDIRECT CONTRIBUTOR
Employed Private Kasambahay Family Driver
Employed Government Listahanan LGU-sponsored NGA-
Migrant Worker
Professional Practitioner 4Ps/MCCT sponsored Private-
Land-Based Sea-Based
Self-Earning Individual Senior Citizen sponsored Person
Lifetime Member
Individual Filipinos with Dual Citizenship / Living Abroad PAMANA with Disability
Sole Proprietor KIA/KIPO PWD ID No.
Foreign National
Group Enrollment Scheme PRA SRRV No. _ _ _ _ _ _ _ Bangsamoro/Normalization
_ _ _ _ _ _ __ ACR I-Card No. _ _ _ _ _ _ _
For PhilHealth Use only:
PROFESSION: (Except Employed, Lifetime Members
and MONTHLY INCOME: PROOF OF Point of Service (POS) Financially Incapable
Sea-based Migrant Worker) INCOME:
Financially Incapable
This form may be reproduced and is not for Continue at the back
sale
 V. UPDATING/AMENDMENT
Please check: FROM TO
Change/Correction of Name
(Last Name, First Name, Name Extension (Jr./Sr./III) Middle Name)

Correction of Date of Birth

Correction of Sex

Change of Civil Status

Updating of Personal Information/Address/
Telephone Number/Mobile Number/e-mail
Address

Under penalty of law, I hereby attest that the information provided, including the documents I
FOR PHILHEALTH USE
have attached to this form, are true and accurate to the best of my knowledge. I agree and ONLY
authorize PhilHealth for the subsequent validation, verification and for other data
sharing purposes only under the following circumstances: RECEIVED BY:
 As necessary for the proper execution of processes related to the legitimate and
declared purpose; Full Name:
 The use or disclosure is reasonably necessary, required or authorized by or under the
law; and, _ _ _ _ _ _ _ _ __ __
 Adequate security measures are employed to protect my
information. PRO/LHIO/Branch:

_ _ _ _ _ _ _ _ __ _

Date & Time:

Member’s Signature over Printed Name Date Please affix right _ _ _ _ _ _ _ _ __ __

thumbmark if unable to
write

INSTRUCTION
S

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 relationship between member and dependent/s for updating or request for amendment.
4. On the PURPOSE, check the appropriate box if for Registration or for Updating/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 registrant has no
middle name and/or with single name (mononym).

LAST NAME FIRST NAME NAME EXTENSION (Jr./Sr./III) MIDDLE NAME

SANTOS JUAN ANDRES III 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 registrant/member is married.
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.
13. 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 to the member.
16. Dependents with 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 printed name (or right thumbmark if unable to write) and indicate the date when the
PMRF was signed.