PhilHealth Annex E.3: Checklist of Requirements for Reimbursement – Chemotherapy
Fill PhilHealth Annex E.3: Checklist of Requirements for Reimbursement – Chemotherapy 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, Middle Name, Suffix, 2. PhilHealth ID Number, 1. Checklist of Requirements for Reimbursement – Chemotherapy, 2. Photocopy of approved Pre-authorization Checklist and Request, 5. Photocopy of Member Empowerment Form (Annex B), 6. Checklist of Mandatory and Other Services (Annex C.3), 8. Breast Cancer Treatment Passport (Annex F), 10. Photocopy of the multidisciplinary – interdisciplinary team (MDT) plan, DATE COMPLETED (mm/dd/yyyy), DATE FILED (mm/dd/yyyy), 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.