PhilHealth Annex C.5.3: Checklist of Mandatory and Other Services for Targeted Therapy - Tranche 3
Fill PhilHealth Annex C.5.3: Checklist of Mandatory and Other Services for Targeted Therapy - Tranche 3 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, Middle Name, Suffix, PhilHealth ID Number, Right, DATE OF PRESCRIPTION, 2D Echo, Date conducted, Granulocyte colony-stimulating factor, Antiemetic, specify, Antimicrobials, specify, Pain relievers, specify, Other medicines, specify.
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.