PhilHealth Annex A: Checklist of Eligibility Criteria
Fill PhilHealth Annex A: Checklist of Eligibility Criteria 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: Registry No, 1. Last Name, First Name, Middle Name, Suffix, 2. PhilHealth ID Number, A. For a woman at risk for preterm delivery, 1.1 Early trimester ultrasound (if available), 1.2 Last menstrual period (LMP), 2. Estimated fetal weight (EFW) < 2500 grams, 3. Presence of complications, 3.1 Severe pre-eclampsia, 3.2 Eclampsia, 3.3 Preterm, pre-labor rupture of membranes (pPROM), 3.4 Onset of labor.
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.