I. Personal Details: (Please Indicate Country If Born Outside The Philippines)
I. Personal Details: (Please Indicate Country If Born Outside The Philippines)
I. Personal Details: (Please Indicate Country If Born Outside The Philippines)
210255363063
REMINDERS:
1. Your PhilHealth Identification Number (PIN) is your unique and permanent PURPOSE:
number. REGISTRATION UPDATING/AMENDMENT
2. Always use your PIN in all transactions with 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
MIDDLE MONONYM
LAST NAME FIRST NAME EXTENSION MIDDLE NAME NAME
(Jr./Sr./III) (Check if applicable only)
PROFESSION: (Except Employed, Lifetime Members and MONTHLY INCOME: PROOF OF INCOME: Point of Service (POS) Financially Incapable
Sea-based Migrant Worker) Financially Incapable
N/A N/A
N/A
This form may be reproduced and is not for sale Continue at the back
V. UPDATING/AMENDMENT
Please check: FROM TO
Change/Correction of Name
(Last Name, First Name, Name Extension (Jr./Sr./III) Middle Name)
Correction of Sex
Under penalty of law, I hereby attest that the information provided, including the documents I have
attached to this form, are true and accurate to the best of my knowledge. I agree and authorize
PhilHealth for the subsequent validation, verification and for other data sharing purposes only under the
following circumstances:
l As necessary for the proper execution of processes related to the legitimate and declared
purpose; PRO/LHIO/Branch:
l The use or disclosure is reasonably necessary, required or authorized by or under the law; and,
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).