PhilHealth Annex A: Checklist of Eligibility Criteria for Physical Medicine and Rehabilitation
Fill PhilHealth Annex A: Checklist of Eligibility Criteria for Physical Medicine and Rehabilitation 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, The patient must be at least 18 y/o and above at the time of, Currently Receiving Physical Medicine and Rehabilitation Services, Date of Assessment by a Physiatrist/Physical Medicine and, Continued Physical Medicine and Rehabilitation Services are, Mobility and Self-, Cognitive, Communication, Certified correct by.
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.