PhilHealth Annex F.4: Checklist of Requirements for Reimbursement - Assistive Mobility Devices
Fill PhilHealth Annex F.4: Checklist of Requirements for Reimbursement - Assistive Mobility Devices 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, c. Photocopy of completely accomplished Pre-authorization Checklist and, e. Accomplished Checklist of Requirements for Reimbursement of, f. Accomplished Checklist of Essential Health Services for Physical, g. Photocopy of the prescription for the assistive mobility device, h. Original or Certified true copy (CTC) of the Statement of Account (SOA), 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.