PhilHealth Annex C.1: Pre -authorization Checklist and Request Form for Wheelchairs
Fill PhilHealth Annex C.1: Pre -authorization Checklist and Request Form for Wheelchairs 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, 1. Last Name, First Name, Suffix, Middle Name, 2. PhilHealth ID Number, Same as patient, General Criteria, Not Applicable, (mm/ yyyy) , Inability to walk <400 meters or endure 10 minutes of continuous walking, Place a checkmark () on the appropriate type of Assistive Mobility Device, Certified correct by, PhilHealth Accreditation No, Date signed (mm/dd/yyyy).
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.