PMRF

PHILHEALTH MEMBER REGISTRATION FORM

UHC v.1 January 2020

REMINDERS:
0705 0467 8901
PHILHEALTH IDENTIFICATION NUMBER (PIN)
1. Your PhilHealth Identification Number (PIN) is your unique and permanent
number.
PURPOSE:
2. Always use your PIN in all transactions with PhilHealth. REGISTRATION X UPDATING/AMENDMENT
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 i f app li cable only)

MEMBER
CAMBA JONATHAN FUENTES
MOTHER’s
MAIDEN NAME FUENTES BEATRIZ CASILAN
SPOUSE
(If Married) CAMBA ROSALIE PECSON
DATE OF BIRTH PLACE OF BIRTH (City/Municipality/Province/Country)
(Please indicate country if born outside the Philippines) PHILSYS ID NUMBER (Optional)
1 0 20 1 9 8 2 Olongapo City, Zambales, Philippines
m m d d y y y y
SEX CIVIL STATUS CITIZENSHIP TAX PAYER IDENTIFICATION NUMBER (TIN) (Optional)

X Male Single Annulled X FILIPINO FOREIGN NATIONAL

Female X 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
103, Ilang-ilang Street
(COUN TRY C OD E + AR EA CODE + TELEPHONE NUM BER)
Subdivision Barangay Municipality/City Province/State/Country (If abroad) ZIP Code

Brgy. Sacrifice Valley, Hermosa Bataan 2111 Mobile Number (Required)

MAILING ADDRESS
09469622677
SAME AS ABOVE
Unit/Room No./Floor Building Name Lot/Block/Phase/House Number Street Name Business (Direct Line)

103, Ilang-ilang Street

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

Brgy. Sacrifice Valley, Hermosa Bataan 2111

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

DATE OF NO Check if
NAME MIDDLE MONONYM
BIRTH with
LAST NAME FIRST NAME EXTENSION
(Jr./Sr./III)
MIDDLE NAME RELATIONSHIP
(mm-dd-yyyy)
CITIZENSHIP NAME Permanent
Disability
(Check i f app li cable only)

IV. MEMBER TYPE

DIRECT CONTRIBUTOR INDIRECT CONTRIBUTOR

Employed Private Kasambahay Family Driver
Listahanan LGU-sponsored
Employed Government Migrant Worker
4Ps/MCCT NGA-sponsored
Professional Practitioner Land-Based Sea-Based
Lifetime Member Senior Citizen Private-sponsored
Self-Earning Individual
Filipinos with Dual Citizenship / Living Abroad PAMANA Person with Disability
Individual
KIA/KIPO PWD ID No.
Sole Proprietor 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 INCOME: Point of Service (POS) Financially Incapable
Sea-based Migrant Worker)

Financially Incapable

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 N ame, Name Extension (Jr./Sr./III) Middle Name) Camba, Beatrize, Pecson Camba, Beatriz, Pecson
Correction of Date of Birth

Correction of Sex

Change of Civil Status

Updating of Personal Information/Address/

Telephone Number/Mobile Number/e-mail
Address

FOR PHILHEALTH USE ONLY

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
RECEIVED BY:
authorize PhilHealth for the subsequent validation, verification and for other data sharing
purposes only under the following circumstances:

• As necessary for the proper execution of processes related to the legitimate and Full Name:
declared purpose;
• 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:

Jonathan F. Camba Aug-15-2023
_ _ _ _ _ _ _ _ __ __
Member’s Signature over Printed Name Date Please affix right
thumbmark if unable to write

INSTRUCTIONS

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.