PhilHealth Annex “ A – Developmental Disability ”
Fill PhilHealth Annex “ A – Developmental Disability ” 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, HEALTH CARE INSTITUTION (HCI), ADDRESS OF HCI, PATIENT (Last name, First name, Middle name, Suffix), PHILHEALTH ID NUMBER OF PATIENT, MEMBER (if patient is a dependent) (Last name, First name, Middle name, Suffix), PHILHEALTH ID NUMBER OF MEMBER, Fulfilled selections criteria, If no, specify reason/s and encode, The child’s chronological age is 0 to 17 years and 364 days old, The child presents with functional problems secondary to delays,, Cognitive-adaptive.
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.