PhilHealth CF4
PhilHealth CF4
PhilHealth CF4
CF4
(Claim Form 4)
August 2018
Series #
IMPORTANT REMINDERS:
PLEASE FILL OUT APPROPRIATE FIELDS. WRITE IN CAPITAL LETTERS AND CHECK THE APPROPRIATE BOXES.
This form, together with other supporting documents, should be filed within sixty (60) calendar days from date of discharge.
All information, fields and tick boxes in this form are necessary. Claim forms with incomplete information shall not be processed.
FALSE / INCORRECT INFORMATION OR MISREPRESENTATION SHALL BE SUBJECT TO CRIMINAL, CIVIL OR ADMINISTRATIVE LIABILITIES.
I. HEALTH CARE INSTITUTION (HCI) INFORMATION
1. Name of HCI 2. Accreditation Number
CARAGA REGIONAL HOSPITAL H14015696
3. Address of HCI
RIZAL ST., BRGY. WASHINGTON, SURIGAO CITY
Bldg No. and Name/Lot/Block Street/Subdivision/Village Barangay/City/Municipality Province Zip Code
5. Chief Complaint
4. Sex Male Female
4. Referred from another health care institution (HCI): No Yes, Specify Reason
HEENT: Essentially normal Abnormal pupillary reaction Cervical lymphadenopathy Dry mucous membrane
Others:
5. Physical Examination continued (Pertinent Findings per System)
CHEST/LUNGS: Essentially normal Asymmetrical chest expansion Decreased breath sounds Wheezes
Others:
CVS: Essentially normal Displaced apex beat Heaves and/or thrills Pericardial bulge
Others:
ABDOMEN: Essentially normal Abdominal rigidity Abdomen tenderness Hyperactive bowel sounds
Others:
GU (IE): Essentially normal Blood stained in exam finger Cervical dilatation Presence of abnormal discharge
Others:
Others:
NEURO-EXAM: Essentially normal Abnormal gait Abnormal position sense Abnormal/decreased sensation
Others:
IV. COURSE IN THE WARD (Attach photocopy of laboratory/imaging results) Check box if there is/are additional sheet(s).
Generic Name Quantity/Dosage/Route Total Cost Generic Name (cont) Quantity/Dosage/Route (cont) Total Cost (cont)
I certify that the above information given in this form, including all attachments, are true and correct.
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month day year
Signature over Printed Name of Attending Health Care Professional
Date Signed