PhilHealth Letterhead of the referral facility
Fill PhilHealth Letterhead of the referral facility 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: CBC w/ Platelet count, Fasting Blood Sugar, Fecal Occult Blood, Fecalysis, Lipid Profile, HbA1c, Oral Glucose Tolerance Test (OGTT), Pap Smear/VIA, Sputum Microscopy, Urinalysis, Creatinine, Laboratory.
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.