PhilHealth Annex G.2A: Checklist of Requirements for Reimbursement Using CAPD - Pediatric
Fill PhilHealth Annex G.2A: Checklist of Requirements for Reimbursement Using CAPD - 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, 1. Last Name, First Name, Suffix, Middle Name, 2. PhilHealth ID Number, Same as, B. Photocopy of the completely accomplished Checklist of Eligibility, C. Photocopy of completely accomplished Member Empowerment, C. Accomplished Checklist of Requirements for Reimbursement, D. Accomplished Checklist of List of Essential Health Services Using, E. Original or Certified true copy (CTC) of the Statement of Account, Date Completed (mm/dd/yyyy), Date Filed (mm/dd/yyyy), Certified correct 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.