primary care benefit 1 - Philippine Health Insurance Corporation

enlistment status and remarks and other required fields such as the dates and
signature (See Annex D for Template). The Provider will print the masterlist in this
format to be used during enlistment.
b. Using this form, the Provider will ask the entitled members to enlist to the health
facility by signing the space provided in the form.
c. In the event that the member cannot sign the masterlist, a qualified dependent of
legal age may sign on his/her behalf stating their relationship and the reason why
the member could not sign. If the member cannot write or sign his/her name,
thumb mark is acceptable but it should be witnessed by at least one disinterested
party. This information must be written on the column allotted for remarks.
d. For additional members who enlist but not included in the original masterlist
provided by PhilHealth, the Provider may add them, including other details as
required, at the bottom of the page.
e. The health facility personnel who prepared the report shall certify the correctness of
the updated masterlist and the head of the facility shall approve the report.
f. A copy of the updated masterlist with the signature of members will be submitted to
LHIO.
2. PCB PROVIDER CLIENTELE PROFILE (ANNEX A.2 OF CIRCULAR)
a. This report is a summary of individual or client health profiles of all PhilHealth
members and dependents assigned in your facility. All data in this report are derived
from Annex A.1 (Individual/ Client Health Profile) and masterlist of members. This
report shall be submitted quarterly, within fifteen (15) working days after the
quarter.
b. Filling up Annex A.2
Box I. PCB Provider Data
i.Write the region, province and city/municipality on the space below the label
ii.Indicate the number of assigned families per type of sponsor/membership based on
the masterlist of who are enlisted.
iii.Indicate the number of families served under the catchment area who are not a
PhilHealt members.
Box II. Age ‐Sex Distribution
i. Based on all accomplished Annex A.1, distribute the number of profiled members
and dependents according to age distribution and gender.
ii. Compute for the total no. of members and dependents according to gender. Reflect
this data on the bottom row data fields.
iii. Compute for the total no. of members and dependents according to age
distribution. Reflect this data on the left most column data fields.
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