PhilHealth Annex A.2: Checklist of Eligibility Criteria for Peritoneal Dialysis - Pediatric
Fill PhilHealth Annex A.2: Checklist of Eligibility Criteria for Peritoneal Dialysis - Pediatric 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, Last Name, First Name, Middle Name, Suffix, PhilHealth ID Number, PDD Registry No, Date of Registration, Not Applicable, Date of Last Session, Ongoing Dialysis Session, If yes, indicate the mode of dialysis, The patient must be aged 0 to 18 years old and 364 days, Written informed consent from the parents or legal guardian is, Diagnosed with Chronic Kidney Disease (CKD) Stage 5.
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.