PhilHealth Annex " E1 – Hearing Impairment ”
Fill PhilHealth Annex " E1 – Hearing Impairment ” 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, PHILHEALTH ID NUMBER OF MEMBER, 1. Checklist of Requirements for Reimbursement (Annex E1), 2. Photocopy of approved Pre–Authorization Checklist & Request (Annex A), 4. Completed PhilHealth Claim Form (CF1) or PhilHealth Benefit Eligibility, 5. PhilHealth Claim Form 2, 6. Checklist of Mandatory Service for Hearing Impairment (Annex C1), 8. Photocopy of the ABR waveform tracing or applicable hearing test result.
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.