PMRF Form - Fill, Edit Online, Download & Print - No Signup
PMRF
PHILHEALTH IDENTIFICATION NUMBER (PIN)
UHC v.1 January 2020
I. PERSONAL DETAILS
DATE OF BIRTH
d d
y y y y
CITIZENSHIP
Male
Female
SEX
m m
CIVIL STATUS
Single
Married
Widow/er
PHILSYS ID NUMBER (Optional)
Annulled
FILIPINO
FOREIGN NATIONAL
II. ADDRESS and CONTACT DETAILS
Unit/Room No./Floor Building Name Lot/Block/Phase/House Number Street Name
PERMANENT HOME ADDRESS
Subdivision Barangay Municipality/City Province/State/Country (If abroad) ZIP Code
MAILING ADDRESS
Unit/Room No./Floor Building Name Lot/Block/Phase/House Number Street Name
Subdivision Barangay Municipality/City Province/State/Country (If abroad) ZIP Code
(COUNTRY CODE + AREA CODE + TELEPHONE NUM BER)
Home Phone Number
Mobile Number
(Required)
Business (Direct Line)
E-mail Address (Required for OFW)
DIRECT CONTRIBUTOR
INDIRECT CONTRIBUTOR
Employed Private
Employed Government
Self-Earning Individual
Professional Practitioner
Kasambahay Family Driver
Migrant Worker
Land-Based
Sea-Based
Filipinos with Dual Citizenship / Living Abroad
Foreign National
Listahanan
Person with Disability
Lifetime Member
4Ps/MCCT
LGU-sponsored
Senior Citizen
NGA-sponsored
UPDATING/AMENDMENT
REGISTRATION
This form may be reproduced and is not for sale
PURPOSE:
NO
MIDDLE
NAME
Continue at the back
LAST NAME
FIRST NAME
NAME
EXTENSION
(Jr./Sr./III)
MIDDLE NAME
(Check if app licable only)
MONONYM
PLACE OF BIRTH
(City/Municipality/Province/Country)
(Please indicate country if born outside the Philippines)
Private-sponsored
TAX PAYER IDENTIFICATION NUMBER (TIN) (Optional)
PHILHEALTH MEMBER REGISTRATION FORM
REMINDERS:
Legally Separated
SAME AS ABOVE
Individual
Group Enrollment Scheme
____________________
DUAL CITIZEN
PRA SRRV No. _____________________
MEMBER
MOTHER’s
MAIDEN NAME
SPOUSE
(If Married)
PROFESSION:
MONTHLY INCOME:
PROOF OF INCOME:
PAMANA
KIA/KIPO
Bangsamoro/Normalization
DATE OF
BIRTH
(mm-dd-yyyy)
MIDDLE NAME
FIRST NAME
LAST NAME
Check if
with
Permanent
Disability
MONONYM
RELATIONSHIP
CITIZENSHIP
1.
Your PhilHealth Identification Number (PIN) is your unique and permanent
number.
2.
Always use your PIN in all transactions with PhilHealth.
3.
For Updating/Amendment check the appropriate box and provide details to
be accomplished and submit corresponding supporting documents.
4. Please read instructions at the back before filling-out this form.
III. DECLARATION OF DEPENDENTS
(Use additional form if necessary)
NO
MIDDLE
NAME
(Check if app licable only)
NAME
EXTENSION
(Jr./Sr./III)
IV. MEMBER TYPE
Sole Proprietor
ACR I-Card No. _____________________
PWD ID No. ______________
For PhilHealth Use only:
Point of Service (POS) Financially Incapable
Financially Incapable
Preferred KonSulTa Provider
(Except Employed, Lifetime Members and
Sea-based Migrant Worker)
V. UPDATING/AMENDMENT
Change/Correction of Name
(Last Name, First Name, Name Extension (Jr./Sr./III) Middle Name)
Please check:
FROM
Please affix right
thumbmark if unable to write
Member’s Signature over Printed Name
_________________________________________________
Date
Full Name:
______________________________
PRO/LHIO/Branch:
_____________________________
Date & Time:
______________________________
RECEIVED BY:
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:
_________________
As necessary for the proper execution of processes related to the legitimate and
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.
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.
Correction of Date of Birth
TO
FOR PHILHEALTH USE ONLY
Correction of Sex
Change of Civil Status
Updating of Personal Information/Address/
Telephone Number/Mobile Number/e-mail
Address
