PhilHealth Annex A.6: Pre authorization Checklist and Request for Upper Extremities
Fill PhilHealth Annex A.6: Pre authorization Checklist and Request for Upper Extremities 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, Fulfilled selections criteria, SITE OF INJURY, SURGICAL URGENCY, Emergency: Date of surgery (mm/dd/yyyy), Functional upper extremity prior to injury, Normal or with mild systemic disease or no functional limitation (ASA I & II), With no more than two to three (2 to 3) co-morbid illnesses based on physical, Humerus fractures (proximal and/or; distal and/or; distal), Forearm diaphyseal fractures (radius only or; Ulna only or; both radius.
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.