PhilHealth Annex A.3: Pre -authorization Checklist and Request for Tetralogy of Fallot (TOF) or
Fill PhilHealth Annex A.3: Pre -authorization Checklist and Request for Tetralogy of Fallot (TOF) or online and download the official form as a PDF, ready to print. Every input is mapped to its printed box, so IDs, dates and amounts land digit by digit in the right cells, and a value the form cannot hold is refused with the reason instead of being printed wrong.
What you will need: Case No, Last Name, First Name, Suffix, Middle Name, PhilHealth ID Number, Same as patient, Fulfilled selections criteria, If no, specify reason/s and encode, Age up to 18 years and 364 days (Check if applicable), a. Age 0 to less than 6 months approved by EXPERT PANEL, b. Age 6 months to 9 and 364 days, c. Age 10 years old up to 18 and 364 days and approved by EXPERT, Total Correction of Tetralogy of Fallot, Ventricular Septal Defect (VSD) Closure with Severe Pulmonary Stenosis.
The form is the agency's own, from philhealth.gov.ph (checked 2026-10-14): the PDF you download is that form with your values printed in its boxes.
The free clean PDF is that pack’s shortest form. A later form in the same pack needs the Starter plan (₱499) or above. Preview, check, and verify stay free. Not affiliated with BIR, SSS, PhilHealth, Pag-IBIG or any government agency.