PhilHealth Annex A.1: Checklist of Eligibility Criteria for Diagnostic Tests and Prognostication –
Fill PhilHealth Annex A.1: Checklist of Eligibility Criteria for Diagnostic Tests and Prognostication – 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. Positive (+) breast mass; AND/OR, 2. Palpable axillary lymph node, 4. Biopsy results (malignant breast cancer), 5. Immunohistochemistry (IHC) result 2+, 6. HER2 status results is not clear or equivocal, 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.