PhilHealth Provider Data Record (PDR) for Health Facilities (HFs)

Fill PhilHealth Provider Data Record (PDR) for Health Facilities (HFs) 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: TYPE OF TRANSACTION, Name of the Authorized Representative, Position/ Designation of the Authorized Representative, Address of the Authorized Representative, City or Municipality, Province and/or Region, ZIP Code, Longitude (XXX.XXXXX), Landline and/or Mobile Number, Official Email Address, PHILHEALTH EMPLOYER NUMBER, DOH LTO NUMBER.

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.

Fill PhilHealth Provider Data Record (PDR) for Health Facilities (HFs) now

• The blank form from philhealth.gov.ph