Republic of the Philippines
PHILIPPINE HEALTH INSURANCE CORPORATION
City slate Centre Building, 709 Shaw Boulevard, Piisig City'
I-Ienhhkne 44 I -7442 www.philhcnllh.gov.ph
October 2-1, 2012
PHILHEALTH CIRCULAR
No. ^S - Sol2
@*}
ALL ACCREDITED HEALTH CARE PROVIDERS AND
OTHER CONCERNED
SUBJECT:Mandatory Requirements For Engagement of Health Care
Professionals Who Are Deemed Automatically Accredited By The
General Appropriations Act of 2012 And By PhilHealih Circular
I. GENERAL GUIDELINES
1.As m;mdiHcd by the General Appropriations Act of 2012 and by PhilHealth Circular No. 13 s.
2012, all government, employed health core professionals, including full unit and co-terminus,
shall be deemed automatically accredited as a professional health care provider tor purposes
of the National Health Insurance Program. These automatically accredited professional health
care providers however shall be mandatorily required to submit the following to the
PRO/LHJO before their automatic accreditation becomes fully effective:
a)Application foim (Annex A);
b)Photocopy of updated PRC license;
c)Proofs or employmeni (i.e., Appointment Papers and Service Record),
d)Specialty Board Certificate (as applicable);
e)Proof of Payment of the Participation Fee.
The Participation Fee mentioned in No. 5 shall be as follows:
1.For Physicians:
a.Medical SpecialistsP 1,500
b.General Practitioners and
General Practitioners with TrainingP 1,000
2.For DentistsP 1,000
3.For MidwivesP 500
2.All other healih care professionals who are not deemed automatically accredited as
aforementioned shall be required to undergo and follow the regular process ot engagement.
3. This policy shall apply to all applications received on the effeclivity dare of this ciircuku- and
onwards.
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Republic of the Philippines
PHILIPPINE HEALTH INSURANCE CORPORATION
Citystate Centre Building, 709 Shaw Boulevard, Pasig City
Healthline 441-7444 www.pliilliKaltli.RQv.pli
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II. REPEALING CLAUSE
All provisions of previous issuances that are inconsistent with any provisions of this Circular are hereby
amended/modified/or repealed accordingly while those that are consistent shrill remain in full force and
effect.
III. EFFECTIVITY
This Circular shall take effect fifteen (15) calendar days from publication in a newspaper of general circulation
and shall be deposited thereafter with the National Administrative Register at the University of the
Philippines Law Center
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CERTif^2JjWJCOP_yJ4^rRepublic of the Philippines
*@'PHILIPPINE HEALTH INSURANCE CORPORATION
City State 709 Shaw Blvd , Pasig City
I ^s. @Health line 637-9999 loc 1216, 1217, 1223 & 637-6265; www phllhealth.gov.ph
APPLICATION FORM FOR ACCREDITATION
PROFESSIONAL HEALTH CARE PROVIDER
THE PRESIDENT & CEO
Philippine Health Insurance Corporation
Pasig City,
Sir/Madam:
I,, of legal age, hereby applies for accreditation under Sec. b2 ot k.a.
7875 as amended by R.A 9241 and its Implementing Rules and Regulations thereto. For this purpose, I hereby submit
the followinq pertinent information and documentary requirements.
^CREPITATION NO. | | | [ | | | | | | | | |PHILHEALTH IDENTIFICATION NO | | |-| I I I I I I I I I-
? General Practitioner (GP)
(~J GP w/ TrainingTraining :
[~J Medical Specialist Specialty @
? Dentist
Q Midwife
,2. TYPE OF APPLICATION
Q Initial? Re-accreditation
? Renewal? Upgrading/downgrading
Q Late filerP] w/ gap in accredilalion
.. NAME OF PROFESSIONAL
irst
[4. For Females Only {Mother's Maiden Surname)
.SEX16. CIVIL STATUS 6. CIVIL STATUS
PI Male n Female|? Single GWidow?Married |~|Separated 3
|7. TAX IDENTIFICATION NUMBER (TIN)
I. BIRTHDATE (mm/cid/yyyy)
.1.1.
|9. E-MAIL ADDRESS |10. FAX NO. 1-1-1. MOBILE NO.
2. RESIDENTIAL ADDRESS
No. /St / Brgy Municipality/ City
Zip Code[Contact N<
3. mailing; billing address
No. / St. / Brgy. Municipality/ City
Zip Code|Contact No
|14. PRESENT PLACE OF PRACTICE
No. / St / Bigy. Municipality/ City
Zip Code
15.a COLLEGE/UNIVERSITY 15.b YEAR GRADUATED
16.aPRC NO. 16.b Date Issued (mm/dd/yy)
II
|16.C Valid up to (mm/dd/yy)
17. RESIDENCY TRAINING (For GP with Training)
17. a Name of Hospital: 17 b Address of Hospital
17-cYear
Started
17.d Year
Ended
18. HOSPITAUCLINIC AFFILIATION(S)
119. PARTNER PHYSICIANS (for Maternity Care Package/MCP Providers only)
Middle Name Accreditation No1_
OB
For PhilHealth Use Only
Date Evaluated'
Date Received:
Date hncoded:
so
PhRO
so
PhRO
SO/PhRO (Receiving Module)
PhRO (Dala Entry)
By:
By:
By.
Q_
'hRO
PhRO
PhRO
Control No
Date Paid:
Amt. Paid. . 2008 REVISED WARRANTIES OF ACCREDITATION
A.ELIGIBILITY
1.That I am a Doctor of Medicine/Doctor of Dental Medicine/Midwife duly registered and licensed to practice
my profession by the Professional Regulation Commission.
2.That I shall assure that I maintain active membership in the NHIP by regularly paying my PhilHealth
premium contributions during the entire validity of my accreditation as a professional health care provider
depending on the type of membership that I belong to.
B.COMPLIANCE TO THE NATIONAL HEALTH INSURANCE ACT 1995 (R.A. 7875), ITS IMPLEMENTING
RULES AND REGULATIONS AND PHILIPPINE HEALTH INSURANCE CORPORATION ADMINISTRATIVE
ORDERS
3.That I shall, in the course of my participation by virtue of my accreditation with the NHI Program, conduct
myself strictly and faithfully in accordance with the National Health Insurance Law, its Implementing Rules
and Regulations, Administrative Orders and such other policies, rules and regulations issued by the PHIC
from time to time.
C.CONDUCT OF PARTICIPATION
4.That I shall strictly adhere and abide by the Code of Ethics as prescribed in Section 24, Paragraph 12 of
the Medical Act of 1959, as amended, as well as other laws regarding the practice of my profession.
5.That I shall promote and protect the NHI Program against abuse, violation and/or over utilization of its
funds, and that I will not allow myself to be a party to any act, scheme, plan or contract that is prejudicial
to the Program.
6.That I shall not engage in unethical or illegal solicitation of patients for purposes of compensability under
the NHIP Program.
7.That I agree to abide by practice guidelines or protocols, peer review and payment mechanisms of the
Program.
8.That I agree not to charge over and above the professional fees provided for by the National Health
Insurance Program for beneficiaries admitted to a PhilHealth bed.
9.That I shall see to it that qualified NHI Program benefeciary(ies) are given benefits/services due them,
without delay.
10. That I shall have for PhilHealth purposes, a listing of my schedule of professional fees readily available for
presentation to PhilHealth members, dependents and/or representatives upon request. That I shall issue
an itemized official receipt (OR) for all services provided to PhilHealth members and dependents.
D.INSPECTION AND INVESTIGATION
11.That I hereby recognize the authority of the Philippine Health Insurance Corporation and its duly
authorized representative to any inspection or investigation.
12.That I shall cooperate and submit myself to any investigation as ordered by the Corporation by making
ready and available when required/summoned, all documents and records pertinent to cases under
investigation.
13.That I shall comply without delay any Health Insurance Arbiter's summons, subpoena, subpoena duces
tecum and other legal processes.
In accordance with these warranties, I hereby recognize that the participation in the NHI Program is a privilege
and not a right, and in the event of a breech thereof, I am fully aware that the Corporation by virtue of its powers
under RA 7875 and its Implementing Rules and Regulations, may definitely suspend or perpetually revoke my
accreditation.
I further certify under oath that the above statements are true and correct to the best of my knowledge and
belief
day of, 2at, Philippines.
TIC >^;#m".th i _~
Signature
j.1.0. Republic of the Philippines)op!c- _ |J
City of) S.S. j C[.,,....,;...T.nf'
[F.SAA. OUIAOiT |
Affiant exhibiting to me his/her Community Tax Certificate No.issued
aton.