PhilHealth Konsulta Registration Form (PKRF)
TO BE FILLED-OUT BY THE BENEFICIARY
*
MEMBER
DEPENDENT
PHILHEALTH IDENTIFICATION NUMBER
*
Invalid PIN. It must have exactly 12 digits and only numbers.
DATE
*
FULL NAME
*
HOME ADDRESS
*
Select Province
Select Municipality/City
Select Barangay
DATE OF BIRTH
*
MOBILE NUMBER.
*
REGISTRATION OPTIONS
*
REGISTER TO A KONSULTA PACKAGE PROVIDER (KPP)
REGISTER ALL MY DECLARED MINOR DEPENDENTS
1ST CHOICE KPP
*
2ND CHOICE KPP
*
I HEREBY CERTIFY THAT I HAVE NOT AVAILED OF ANY FREE PRIMARY CARE BENEFIT (FPE) FROM OTHER KONSULTA PACKAGE PROVIDERS. I VOLUNTARILY GIVE MY CONSENT TO ST. DOMINIC MEDICAL CENTER, INC FOR COLLECTION, TRANSMISSION, AND PROCESSING OF MY PERSONAL AND HEALTH INFORMATION FOR THE PURPOSE OF BENEFIT MONITORING AND PAYMENT UNDER THE KONSULTA PROGRAM, IN ACCORDANCE WITH REPUBLIC ACT NO. 10173, ALSO KNOWN AS THE DATA PRIVACY ACT OF 2012.
Submit
