PhilHealth Annex C.1.1: EMORPH Discharge Checklist: Lower Limb Prosthesis
Fill PhilHealth Annex C.1.1: EMORPH Discharge Checklist: Lower Limb Prosthesis 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, 1. Last Name, First Name, Middle Name, Suffix, 2. PhilHealth ID Number, 1. External lower limb prosthesis provided is as prescribed with appropriate, 2. The lower limb stump is free of pain, blister, vascular compromise,, 4. Prosthesis user possesses competent skill and knowledge regarding prosthesis, Certified correct by, PhilHealth Accreditation No, Date signed (mm/dd/yyyy), Conforme by.
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.