PhilHealth Annex E.6: Checklist of Requirements for Reimbursement – Surveillance
Fill PhilHealth Annex E.6: Checklist of Requirements for Reimbursement – Surveillance 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 – Surveillance, 3. Photocopy of approved Pre-authorization Checklist and Request (Annex A.2), 4. Photocopy of Member Empowerment Form (Annex B), 7. Checklist of Mandatory and Other Services (Annex C.6), DATE COMPLETED (mm/dd/yyyy), DATE FILED (mm/dd/yyyy), Certified correct by, Conforme by, PhilHealth Accreditation No.
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.