PhilHealth Annex F: Checklist of Requirements for Reimbursement
Fill PhilHealth Annex F: Checklist of Requirements for Reimbursement 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, Suffix, Middle Name, 2. PhilHealth ID Number, Same as patient (Answer only if the patient is a dependent), 2. Photocopy of the MDT Plan, 5. Properly Accomplished PhilHealth Claim Form 2 (CF2), 8. Checklist of Requirements for Reimbursement (Annex F), 10. Transmittal Form (Annex I), 13. Photocopy of Anesthesia Record or similar documents, Date Completed (mm/dd/yyyy), Date Filed (mm/dd/yyyy), Certified correct.
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.