Republic of the Philippines

PHILIPPINE HEALTH INSURANCE CORPORATION

Citystate Centre, 709 Shaw Boulevard, l'asig City
Call Center. (02) 8441 -7442 I Trunklinc: (02) 8441-7444
www.ph ilhcalth.~ov.ph

UNIV ERSAL H EAlTH CARE

TO ALL PHILHEALTH MEMBERS, ACCREDITED HEALTH CARE

INSTITUTIONS/ PROVIDERS, PHILHEALTH REGIONAL
OFFICES, BRANCHES, LOCAL HEALTH INSURANCE OFFICES
AND ALL OTHERS CONCERNED

SUBJECT COVID-19 Home Isolation Benefit Package (CHIBP)

I.

To ad , ess the COVID-19 global pandemic, the President of the Philippines, through
Republi Act No. 11469, also known as Bayanihan to Heal as One Act, and Presidential
Procla ation No. 929 s. 2020 declared a State of Public Health Emergency. In response,
PhilHe th developed COVID-19 benefits to cover for cases requiring community isolation,
testing, nd hospitalization. Amidst the recent surge of COVID-19 cases in the Philippines,
there is a notable rise in hospital admissions for COVID-19. The One Hospital Command
of DO reported on April 1, 2021 that 41% of hospital beds are being occupied by mild
cases, hich if rationalized could be used to manage COVID cases requiring higher level of
care. ·s is in consonance with reports showing that at the peak of the surge at least 95% of
beds w· · NCR were already occupied. Dealing with the surge situation requires better
manage em of mild and asymptomatic COVID-19 cases and hospital resources should only
be utiliz d for moderate, severe, and critical COVID cases.

Given e aforementioned, PhilHealth, by virtue ofPhilHealth Board Resolution No. 2621 s.

2021, h s developed a home isolation package that is consistent with DOH Department
Memor ndum No. 2020-0512 released on November 26, 2020. The COVID-19 Home
Isolatio Benefit Package (CHIBP) will serve as an alternative for patients who meet the
social a d clinical criteria for home isolation and who do not want to stay in a Community
Isolatio Unit (CIU) and can instead receive health support direcdy in their homes.

II. OBJE

The foil wing are the objectives of this package:

A. Supp rt the rationalization of use of higher level facilities to focus on moderate, severe
and ·tical COVID-19 cases;
B. Ince tivize facilities who can offer home isolation services; and
C. Prov de an alternative option for isolation of a COVID-19 confirmed mild and
tomatic patients who meet the social and clinical criteria for home isolation.

III. SCOP

ealth Circular shall apply to all claims for home isolatio n services filed by
accredit d PhilHealth isolation facilities, infirmaries, hospitals and Konsulta providers who
have ac omplished the necessary documentary requirements to provide the CHIBP.

0 PhiiHealthofficial O O teamphilhealth e actioncenter@philhealth.gov.ph

 IV. DEFIN TION OF TERMS

A. Asy · ptomatic - any patient who tested positive for RT-PCR but with no s1gns and
symp oms of COVID-19 disease

B. Bara ay Health Emergency Response Team (BHERT) 1 - a team established by

Dep trnent of the Interior and Local Government (DILG) MC No. 2020-023 to help
impl ment local prevention and mitigation, preparedness and res.ponse measures for
CO ID-19.

C. Co unity Isolation Units (CIUs) 2- DOH certified publicly or privately-owned non-

hosp tal facilities set-up in coordination with or by the national government or local
gove nment units to serve as quarantine facilities for COVID-19 cases, based on DOH
guid lines. Examples of CIUs include LIGTAS COVID Centers and Mega LIGTAS
CO ID Centers.

D. Enh need Community Quarantine (ECQ) 3 - refers to the implementation of

tern orary measures imposing stringent limitations on movement and transportation of
peo e, strict regulation of operating industries, provision of food and essential services,
and heightened presence of uniformed personnel to enforce community quarantine
prot cols.

E. Isolltion4 - the separation of ill or infected persons from others to prevent the spread of
infe cion or contamination.

F. Mil 5 - Symptomatic patients presenting with fever, cough, fatigue, anorexia, myalgias;
oth+ non-specific symptoms such as sore throat, nasal congestion: headache, diarrhea,
nauS'ea and vomiting; loss of smell (anosmia) or loss of taste (ageusia) preceding the onset
of respiratory symptoms with NO s1gns of pneumorua or hypoxia.

G . Mo ified Enhanced Community Quarantine (MECQ) 6 - refers to the transition

1

pha e between ECQ and GCQ, when the following temporary measures are relaxed and
bee ·me less necessary: stringent limits on movement and transportation of people, strict
re arion of operating industries, provision of food and essential services, and
heig• tened presence of uniformed personnel to enforce community quarantine protocols.

H. Sur · e areas - COVID-19 high-risk geographic areas declared by the Inter-Agency Task
For e (IATF) for the Management of Emerging Infectious Diseases to be under
I

EC / MECQ or as defined in relevant issuances7 and/ or as determined by the

Co oration.

1
Joint Admini1 ative Order No. 2020-000 I: Guidelines on Local Isolation and General Treatment Areas for
COVID-1 9 case (LIGTAS COVID) and the Community-based Management of Mild COVID-19 Cases
2
ibid
Inter-Agency T k Force for the Management of Emerging Infectious Diseases (IATF) Omnibus Guidelines on the
ImplementationJf Community Quarantine in the Philippines with Amendments as of March 28, 2021
3
Inter-Agency IJask Force for the Management of Emerging Infectious Diseases (IATF) Omnibus Guidelines on the
Implementation pfCommunity Quarantine in the Philippines with Amendments as of March 28,2021
4
Joint Adminisi rative Order No. 2020-0001 : Guidelines on Local Isolation and General Treatment Areas for
COVID-1 9 case (LIGTAS COVID) and the Community-based Management of Mild COVID-19 Cases
5 DOH Departm nt Memorandum No. 2020-0381: Interim Guidelines on the COVID-1 9 Disease Severity

C lassification arljd Management

6
Inter-Agency f ask Force for the Management of Emerging Infectious Diseases (IATF) Omnibus Guidelines on the
Implementation f Community Quarantine in the Philippines with Amendments as of March 28, 202 1
7
DOH Departm nt Memorandum No. 2021-0327: Interim Guidelines on COVID-19 Surge Response Plan for Health
..~"''.- ac ilities Page 2 of 5
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 I. T ele onsultation8 refers to the consultation done through telecommunications with
-

the p ose being diagnosis or treatment of a patient, with the sites being remote from
patie t or physician

V. POLICY TATEMENTS

A. Rules£ r Accreditation in Providing the COVID-19 Home Isolation Benefit Package

(CHIB )

1. Onl interested PhilHealth-accredited facilities in surge areas9 may apply for re-
accr ditation as CHIBP provider. No accreditation fee shall be charged. Re-
accr . ditation shall be valid until end (December 31) of the calendar year.
2. P · ealth-accredited Community Isolation Units (CIUs), Infirmaries, Hospitals, and
Ko sulta providers shall be allowed to provide the CHIBP.
3. Int rested PhilHealth accredited facilities shall submit additional documentary
req · ements as follows:
a. ompletely filled-out CHIBP Self-Assessment Tool (Annex A: CHIBP Self-
1

ssessment Tool) and Letter of Intent;

igned Performance Commitment as CHIBP provider (Annex B: Performance
ommitment);
c. · ervice Delivery Support and/ or an Authorization Letter under the following
onditions:
.1. PhilHealth Konsulta facilities and infirmaries shall include in their submission a
signed Certification of Service Delivery Support with a L1 to L3 hospital (Annex
C: Certification of Service Delivery Support with a Referral Facility) for referral
in accordance with PhilHealth policy on COVID-19 inpatient benefit or referral
plan to include transportation arrangement;
.2. If the PhilHealth-accredited facility intends to engage the services of a
telemedicine provider, the facility shall submit a signed Certification of Service
Delivery Support with the telemedicine provider (Annex D: Certification of
Service Delivery Support with a qualified telemedicine provider); and,
.3. For facilities with no eClaims system (e.g. Konsulta providers), they should have
an agreement with another PhilHealth-accredited provider that will file, submit
claims and receive payments electronically on their behalf, in a way that is
0 consistent with existing PhilHealth guidelines and procedures. The facility shall
0 submit an authorization letter for the use of the eClairns system of their partner
provider (Annex E: Authorization Letter for Use of eClairns System).

ackage

Home Isolation Benefit Package (CHIBP) shall include all identified

servic s needed to effectively manage COVID-19 confirmed asymptomatic and mild cases
nee · g isolation, based on existing relevant clinical practice guidelines and as approved by
the C rporation (Annex F: COVID-19 Home Isolation Benefit Package Services).
2. Tes · g and inpatient services for COVID-19 patients shall be covere~ by other applicable
COV D-19 case rates.

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8 Deldar, 20 16; V n Dyk, 20 14
to the defi ;,;on of tenns Page 3 of 5

~ t. •; 0 PhiiHealthofficial CjC) teamphilhealth e actioncenter@philhealth.gov.ph

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 3. The p ckage shall be implemented only in surge areas declared by the Inter-Agency Task
. Force IATF) for the Management of Emerging Infectious Diseases. The package shall be
paid a a case rate (see Annex G: CHIBP Package Rate and Rules on Co-pay).
4. Heal care workers identified to be part of the Home Isolation Team (Annex A: CHIBP
Self-A sessment Tool) shall be provided additional incentives (i.e. hazard pay) by the
accre ted health care facility.

C. Availmer of the Benefit Package for Home Isolation

1. All F+ pinos registered under the National Health Insurance Program (NHIP) shall be
eligibl to avail of the program benefit. Filipinos who are not yet registered under the
progr shall automatically be covered, provided that they complete and submit an
acco lished PhilHealth Member Registration Form (PMRF) for the issuance of the PIN
upon vailing of the benefit package.
2. Only eneficiaries who passed both the clinical and social criteria sh~ll be eligible to avail
of the benefit. The beneficiary shall be assessed by the BHERT using an assessment form
(Anne H: Assessment Checklist of Clinical and Social Criteria for COVID-19 Home
Isolati n Benefit Package).The required assessment form shall be downloaded and printed
by th member and submitted to the BHERT upon the latter's visit. The PhilHealth
Regio5lOffice/Local Health Insurance Office shall provide the printed forms to Local
Gove ent Units in anticipation of cases where affected members are not able to
downl ad and print the form.
3. Eligi~ le beneficiaries may check the PhilHealth website for the list of their preferred
CHIB provider.
4. All IBP claims shall be submitted electronically with complete documentary
requir€ments (Annex I: Claims Requirement).
5. Direct filing of claims by the beneficiaries shall not be allowed.
6. All cl s submitted shall be processed by PhilHealth within sixty (60) calendar days from
receip of claim provided that all requirements are submitted.
1

7. The filing period for claims shall be subject to prevailing PhilHealth policies and guidelines
inclucilng special privileges granted during fortuitous events.
8. ClaimE;vith incomplete requirements or discrepancies shall be returned to hospital (RTH)
for co pliance within 60 calendar days from receipt of notice.
1

9. The a credited facility may apply for motion for reconsideration for all denied claims
based n existing PhilHealth policies. .
10. In cat es where the patient experiences clinical deterioration during the home isolation
perio , the facility shall refer the patient to a higher level facility in accordance with DOH
stand rds and guidelines. The accredited PhilHealth facility may file for CHIBP claim for
patie ts transferred to higher facilities due to clinical deterioration even if the period of
1

isola on is less than ten (1 0) days.

11. In th event that the patient expires due to COVID-19 in the course of home isolation,
the a credited facility shall be eligible to file a claim for the CHIBP.

D. Rules on Consultation, Patient Monitoring, and Teleconsultation ·

1. In£ lrmed consent (Annex K: Authorization and Consent to Participate in Telemedicine

Codsultation) must be secured from patients. The health care providers must apprise
pari nts of their rights and inform them of the risks and limitations of telemedicine at
the tart of each teleconsultation.
2. The initial encounter to determine whether the patient is eligible for home isolation shall
be onducted by the physician through face-to-face consultations.
3. The CHIBP shall allow for subsequent consultations and daily monitoring (Annex L:
Ho e Isolation Patient Monitoring Sheet) of patients for home isolation through
1

tele onsultation, either through telephony or video consultations.

4. The provision of teleconsultations shall be done in accordance with prevailing DOH
Page 4 of 5

0Phi1Healt hofficial O Oteamphilhealth (i} actio ncenter@philhealth.gov.ph

 rules and guidelines in telemedicine practice (DOH-UP JMC 2020-0001) and shall be
com liant with data privacy laws.

E.

1. All hilHealth-accredited facilities claiming for this benefit package shall be subject to
the ' les on monitoring prescribed by PhilHealth.
2. Fee back mechanisms on the package implementation shall be established to address
imp ementation issues and concerns.
3. P · ealth shall conduct a perio dic review of this policy and specific provisions shall be
revi ed as needed.
4. The accredited facility shall keep the patient's medical chart and monitoring sheet.
The . e records must be made available upon the request of PhilHealth.

F. Annexe (To be posted via PhilHealth website)

~ Annex A CHIBP Self-Assessment T ool

g Annex B Performance Commitment

~l l
Annex C Certification of Service Delivery Support with a Referral Facility
l 03-- Annex : Certification of Service Delivery Support "vith a qualified telemedicine provider
Annex E Authorization Letter for Use of eClaims System
cr 6j Annex F COVID-19 Home Isolation Benefit Package Services
Ll..l>- "''-

i8~i
Annex : CHIBP Package Rate and Rules on Co-pay
Annex : Assessment Checklist of Clinical and Social Criteria for COVID-19 Home
Isolation Benefit Package
Annex I: Claims Requirement
~ Annex]: Certification of COVID-19 Home Isolation Kit Issuance
<.:5 Annex I :Authorization and Consent to Participate in Telemedicine Consultation
0 Annex L Home Isolation P atient Monitoring Sheet

VI. PENALTr CLAUSE

Any viola ·on of this PhilHealth Circular, terms and conditions of the Performance
Commitm nt, and all existing related PhilHealth Circulars and directives shall be dealt with
according! .

VII .

ealth Circular shall take effect fifteen (15) days after publication in any newspaper
circulation. A copy thereof shall be deposited thereafter with the Office of the
•u~·,J..I.strative Register at the University of the Philippines Law Center.

.G RRAN,CP~
~~~;u:M;H:::1rii..1 Executive Officer (V'CEO)

Date signed: ---->;..oJ---+~.:....._-_...,_P_._l-'--4-

COVID-19 Home Is lation Benefit Package (CHIBP)

~ ------~---------------------------------------------Pa_g_es_o_f-
5
\• .I ) 0 PhiiHealthofficial OOteamphilhealt~ eactioncenter@philhealth.gov.ph
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AnnexA
Self-Assessment/Accreditation Survey Tool for
PhilHealth COVID 19 Home Isolation Benefit Package
(CHIBP)
Name of Facility:
Address:
Contact Number: Email:
Ownership of Health Facili~ : 0 Government 0 Private
Date of Assessment: (tvfM/D PIYY):

Type of Health Facilities:

0 Hospital OPD Dept./Sec ~on (Level ) 0 Konsulta Provider
0 Infirmary OPD D ept. /Se tion
0 CIU
PhilHe alth Accreditation N1 mber Accreditation Validity

MINIMUM ACCREDITAT I ON REQUIREMENTS Applicant PhiiHealth Surveyor

Please check Please mark with check
(")the box (") if present (indicate
corresponding evidence provided: photos,
to your answer REMARKS
videos/ virtual
observation), or mark with
X if absent
Yes No Yes No
1. DOH licen se (for hospital and infirmaries)
2. Updated Signed performat ce commitment
3. Home Isolation Team - ~mployed or contracted by the facili ty
3.1. Certification of E mp oyment/Contract Arrangement
3.2. Telephone number:
3.3. Email address:
4. Schedule of duties
5. Physician:
5.1. Valid PRC License
5.2. Updated Phi!Health \ccreditation
5.2.1. PhilHealth Ace ·editation Number
6. Nurse
6.1. Valid PRC License

7. General Infrastructure 0 Provider (Provide evidence: Photos, I f any O NE

videos, virtual observatio n of the items
7.1. Dedicated room and IT equipment for daily operation IS rrusstng,
7.2. Functional Toilet (*f, r employees) mark NO.
7.3. Fire safety provision
8. Home isolation kit (shall ensure availability once accreditation is
granted)
a. 1 liter 70% alcohol
b. 5 pes. Face mask
c. 1 pulse oximeter
d . 1 digital thermomete
c. Drugs and medicatiot, s (18 pes. Paracetamol, 12 pes. Lagundi
tablets or equivalent, r sachets oral rehydration salts, 10 pes
Vitamin D and 10 pc Vitamin C)
f. .Authorization and Cc nsent to Participate in Teleconsultation
9. OTHER REQUIREME NTS
9.1. Referral Plan - Func ~ona l referral system from the
community to highe level of health care facility, as applicable
9.2. Service D elivery Agr ement (tvfOi\./Contract) with referral
facility, as applicable
9.3. Service D elivery .Agr ement with a qualified telemedicine
provider (optional)
9.4. Health facility has fu 1ctional medical record (CIU and
Konsulta providers c nly)
-
:9.
c-
Prepared by: "35
0: ru
uJ.>- "'ro
rCL(
c:;_o
H ead of F acility/ Medical Director/ Chief of Hospital
(Signature over printed name and date signed)
(De. ·gnation) ~(.) ~
~

(.)
Attes ted correct by: 0
 .

ANNEXB
Aug. 2018

(Letterhead of Healthcare Provider)

(Date)

PHILIPPINE H EALTH INSURANCE CORPORATION

17th Flr., City Sta t Centre Bldg.,
Shaw Blvd., Pasig ~ity

SUBJECT : Performance Commitment for HCI (Rev 3)

Sir/Madam:
To guarantee our omm..itrnent to the National Health Insurance Program ("NHIP"), we respectfully submit
. ~.

this Performance ~omrrutrnent.

And for the purp< ses of this Performance Comm..itment, we hereby warrant the following: representations:

A. REPRESE NTATION OF ELIGIBILITIES

1. T hat we ~re a duly registered/licensed/ certified health care facility capable of delivering the
serv1ees xpected from the type of health care provider that we are applying for.
2. That we are a member in good standing of the Philippine Hospital Association. (for hospitals
and inflr naries only).
3. a. For si gle H CI
T hat we are owned by
and mar. aged by
and doir g business under the name of
with Lie nse/Certificate No.

b. For r ealth Systems/ HCI groups

That th follo\ving facilities, as guaranteed by the heads of facilities listed in the following table,
are capa ble of delivering the servic~s expected from the type of healthcare provider that we are
applyin for:
~ Name of T ype of facility Hospital License Manageme
9. Facility (hospital, RHU /J-IC, Level (if Number/ Cert:i nt (if

0:
;ICj
,_
Birthing home/ Lying-
in, ASC, dialysis clinic
(HD/ P D), TB-DOTS,
applicable) fi.cate N umber
(if applicable)
different
from the
LGU)
LU>- (tl ABTCs, DRTC,
I-- £L Cl OHAT, etc.)

J8~
. {j
OJ
- Page 1 of 6 of Annex B

-
 That all rofessional health care providers in our facility, as applicable, are PhilHealth
accredite , possess proper credentials and given appropriate privileges in accordance with
our poli es and procedures.
··;.

B. COMPLI CE TO PERTINENT LAWS/RULES & REGULATIONS

/POLIC ES/ ADMINISTRATIVE ORDERS AND ISSUANCES
Further, we reby commit ourselves to the following:
4. That our fficers, em ployees, and other personnel are members in good standing of the
N HIP.
5. That, as r sponsible owner(s) and/ or manager(s) of the institution, we shall be jointly and
sevenJ..ly ·able for all violations committed against the provision;; of Rep. Act No. 7875
including its Impl~a1cnting Rules and Regulations (IRR) and Phi1Healtl1 policies issued
pursuant hereto.
6. That we hall p romptly inform Phi.lHealth prior to any change in the ownership and/ or
manage ent of our institution.
7. That any hange in ownership and/or management of our institution shall not operate to
exempt tf e previous and/ or p resent owner and/ or manager from liabilities for
violati.onl of Rep. Act No. 7875, as amended, and its IRR
8. That we ·hall maintain active membership in the N.HIP as an employer no! only during the
entire va1dity of our participation in the NHIP as a H ealth Care Institution (HCI) but also
during t corporate existence of our institution.
9. That we hall abide with all the implementing rules and regulations, memorandum circulars,
special o ders, advisories and other administrative issuances by PhilHealth affecting us.
10. That we hall abide with all administrative orders, circulars and such oth er policies, rules and
regulatio s issued by the Department of Health and all other related government agencies
and instr mentalities governing the operations of HCis in participating in the NHIP.
hall adhere to pertinent statutory laws affecting the operations of HCis inclucEng
·ted to the Senior Citizens Act (R.A 10645), the Breastfeeding Act (R.A. 7600), the
Screening Act (R.A. 9288), the Ch eaper Medicines Act (R.A. 9502), the Pharmacy
Law (R. . 5921), the Magna Carta for Disabled Persons (R.A. 9442) , and all other laws, rules
and reg ations that may hereafter be p assed by the Congress of the of the Philippines or any
other au horized instrumentalities of the government.
12. That we hall p romptly submit reports as may be required by PhilHealth, DOH and all other
gover ent agencies and instrumentalities governing the operations of HCis.
13. That we shall facilitate distribution o f the professional fee componen t of the Phill-Iealth
paymen /reimbursement to the concerned professionals not exceeding thirty (30) calendar
days up n receipt of the reimbursement or at a time frame as agreed upon by the H CI and
their pr fessiona.ls. ·
14. That bei g a government-owned health care institution, we shall maintain a trust fund for
the Phil ealth reimbursements in compliance to Section 34-A of Republic Act 10606 which
provide that "revenues shall be used to defray operating costs other than salaries, to

Page 2 of 6 of Annex B
 maintain r upgrad e equipment, p lant or facility, and to maintain or improve the quality of
care.

C. CONDU CT OF CLINICAL SERVICES, RECORDS, PREPARATION OF CLAIMS

AND UNDE~TAKINGS OF PARTICIPATION IN THE NHIP
15. a. For sin e H CI:
That we a e duly capable of delivering the following services for d1e duration of the validity of
this comrr "tment (please check appropriate boxes):
0 Primary Care Facility
D Level 1 hospital se:vice5
D Le-vd 2 hospilal services
0 Level 3 h ospital services
0 Specialized ~ervices
·O Radiotherapy
D Hemodialysis/Peritoneal D ialysis
D Others (please specify) - - - - - - - - - - - - - - - -
0 Bendi~ package and ot1er setvices
0 Tuberculosis Direcdy Observed Treatment Sh ortcourse (fB D O T S)
0 Maternity Care Package
L.J N ewborn Ca::e Package
0 Malaria Package
0 E xpanded Primary Care Benefit Package (EPCB)
0 Outpatient HIV /AID S Package (for DOH identified hospitals only)
0 Anim~d Bite P:1ckage
0 Z Benefit Package/s
0 Others(pleas!! specify) _ _ __ __ _ _ _ _ _ __ _ __
-- ------·- ···- -- - - -- - -- - - - - - -- -

b. For He lth Systems/ H CI grcups

That we s 1all deliver the fcllo~·ing scrvict:s for the duration o f the validity of this commitment:
Name o f Facility <:ommitted Services (ch oose from the enumerated services
~---+----1-a_b_o__,·~--------·----------------~

r--· - · ---+-- -- -- - - -- - - - - - -- - -- -- -- -- - - - - -- --1

1--·- -·-+- - -·- -i-- - ---··- - - -- -- · -- - - -- -- -- - -- - - - --l

(.j '----· - - ------~--- --------- -----------------__J
0

16. That we hall provid e and charge to the PhilHealth ben efit of the client the necessary
sem ces 1 eluding but no t limited to drugs, m edicines, supplies, devices, and diagnostic and
treatmen procedures for our P hilHealth clients.
17. That we, being an accredited government hospital or infirmary/ ASC/ FDC / MCP / TB
DOTS/ nimal Bite package/ DRTC/ P CB and / or contracted provider for the Z benefit

Page 3 of 6 of Annex B
 package ovider, as applicable, shall provide the necessary drugs, sup plies and services with
pocket expenses on the part of the qualified P hilHealth member and their
depende ts admitted or who consulted in the HCI, as mandated by the PhilHealth "No
Balance illing (NBB) P olicy"
18. That we, eing an accredited provider, shall abide by the rules set in the respective b enefit
package, ncluding the prescribed disposition and allocation of the PhilHealth
reimburs m ents, as stated in the current guidelines, which shall be used by the HCI to be
able to p vide the mandatory services and ensure better health outcomes.
19. That we, eing an accredited EPCB/contracted Z benefit provider/s, as applicable, shall
post the o-payment for the drugs/ diagnostics or other services, as applicable, in a
conspicu us area within the HCI.
20. That we, eing accredited E PCB provider commits to provide service to a maximum daily
patient lo d of _ _ and maximum annual family load o f _ _ that the HCI can cater to
and that e shall not exceed this number.
21. That we hall maintain a high level of service satisfaction among Phill-Ieal~ clients including
all their alified dependents/beneticiarie:s.
22. That we hall be guided by PhilHealth-approved clinical practice guidelines or if not
available, other established and accepted standards of practice.
23. That we hall provide a Phill-Iealth Bulletin Board for the posting of updated information of
the NHI (circulars, memoranda, IEC materials, price reference index, etc.) in conspicuous
places ac essible to patients, members and dependents of the NHIP within our health
facility.
24. That we hall always make available the necessary forms for PhilHealth member-patient's
usc.
25. That we hall treat PhilHealth member-patient with utmost courtesy and resp ect, assist them
in availin , Ph.ilHealth bmdits and proYide them with accurate infom1ation on PhilHealth
policies nd guidelines.
26. That we hail ensure that Phili-Jealth member-patient with needs beyond our service
capabili are referred to appropriate PhilHealth-accredited health facilities.

D. MANAGEME T INF ORMATION SYSTEM

27. That \.ve hall ~naintain a registry of all our PhilHealth members-patients (including
n ewbon s) and a database of all claims filed containing actual charges (board, drugs, labs,
au:cli.ary services and prcfessional fees), actual amount deducted by the facility as PhilHealth
reimbur emem and actual Phill-Iealth reimbursement, which shall be made available to

~
Pb.ilHeal h or any of its authorized personnel.
28. That we shall maintain and submit to Ph.ilHealth an electronic registry of physicians and
cr: Ci dentisrs ncluding their fields of practice, official e-mail and mobile phone numbers.
w>- ""-
ro
29. That we shaD, if connected with e-claitTlS, electronically encode the laboratory / diagnostic
.... a.. 0

~
examina ·ons done, drugs and supplies used in the care of the patient in our information
~
~(.) system -1-Lich shall be made ava.ilab:le for Ph.ill-Iealth use.
30. Th:H we shall ensure that true and accur::tte data are encoded in all p atients' records.
31. That we sha)J. only file true and legitim~.te claims recognizing the p eriod of filing the same
i.3 aft~r tl:le patient':> di~;ch::ng(~ as prescribed in PhilHealth circulars.
0
32. Thac we shaH submit. claims in the formar required by PhilHealth for our facility.

Page 4 of 6 of Annex B
 all regularly submit PhilHealth monitoring reports as required in P hilHealth
circulars.
34. That we s :1all annually submit to PhilHealth a copy of our audited financial
report, to include the disposition of PhilHealth reimbursement.

E . REGU SURVEYS / ADMINISTRATIVE INVESTIGATIONS / DOMICILIARY

VISITATI NS ON THE CONDUCT OF OPERATIONS IN THE EXERCISE OF
THE PRI ILE GE OF ACCREDITATION
35. That we sl all extend full cooperation with duly recognized authorities ofPhilHealth and any other
authorize personnel and instrumentalities to provide access to patient records and submit to any
orderly as essmem conducted by PhilHealth relative to any findings, adverse reports, pattern of
uti.lizatio and/ or any other acts indicative of any illegal, irregular and/ or unethical practices
in our op ·rations as ~'n accrecli~~d HCI of the NHIP tlut may be prejudicial 0r tends to
und.::ri'l'j t c tb: N:-IlP and mak~ ~tv:Uabl,_: ill pertinen t official records and docu..."TTtut~
inclu:.iing the J?l0'7!S~o•1 of copies thereof; provid ed that our rights to private ownership an d
privacy a. e respected at all rimes.
36. That we h all ensure that cur officer~, employees and personnel extend full cooperation and
due cour esy to all Philllealth officers, employees and staff during the conduct of
assessnH: lt/v:isitation/investigacion/monitoring of our operations as an accredited HCi of
the j\~' Hl
37. That ar a y time dw-ing che period of our participation in the N H IP, upon request of
Phill-leal 1, w.:. shall voluntarily sign and ~:,ecute a new 'Performance Commitmenr' to cover
the rema'11ng portion of our accreditation or to renew our particip ation \vith the NHIP as
the Gt$C r 1ay Lc, as a sign of our good faith and continuous commim1ent to support the
NHIP.
38. That, unl ss proven to be a palpable mistake or excusable error, we shall take full
responsil ility for any inaccuracies and/or falsities entered into and/ or reflected in our
patients' ec•1rds a~. 'Vell a~ in any omission, addition, inaccuracies and/ or falsities entered
into and or ret1ected in claims subrnitted to PhilHealth by our institution.
39. That we hall comply with PhilHealth's summons, subpoena, subpoena 'duces tecum' and
other leg-. I or qual..iry assurance processes and requirements.
40. That '\Ve hall recognize the authority of PhilHealth, its Officers and personnel and/ or its
duly aut. ·)rized representatives to conduct regular surveys, domiciliary visits, and/ or
conducr dministrative assessments at any reasonable time relative to the exercise of our
privilew~ nd conduct of our operations as an accreclited HCI of the NHIP .
41. That \Ve hall comply with Phi..!Health corrective actions given after monitoring activities
\yjthin th . prescribed period.

F. M iscellan .ous Provisions

42. That we hall pwtcct the NHIP against ::tbuse, violation and/ or over-utilization of its funds
and we s 1:1llnut allow 0'-1r instit1n.ion ro be a party to any act, scheme, p lan, or contract that
may dire tly or indirectly be prejudicial or detrimental to the NHIP .
. T~1:1t we haU not directly or indirectly engage in any form of unethical or improper practices
as an ace edited health care pro-vider such as but no t limited to solicitation of patients for
purpose of compensability under the NHIP, the purpose and/or the end consideration of
wiUcn ce .ds unnecessary financial gain r:1ther than promotion of the NHIP.

Page 5 of 6 of Annex B
 44. That we s 1all immediately repon to Phill-Iealth, its Officers and/ or to any of its personnel,
any act o illegal, improper and/ or unethicd practices of HCI of the NHJP that may have
come to r knowledge directly or indirectly.
45. That we s all allow PhilHealth to deduct or charge to our future claims, ali reimbursements
paid to 0 institution under the follo'W1ng, but not limited to: (a) during the period of its
non-accre ·ted status as a result of a gap in validity of our DOH LTO, suspension of
accredita o n , etc; (2) downgrading of level, loss of license for certain services; (c) when NBB
eligible P ·11-Jealth m ember:> and their dependents were made to pay out-of-poc\et for HCI
and pro ft sional fc:es, if applicable; (d) validated claims of under deducriou of Pb.il.Health
b en efits .
Furthu more, ·ecognizing and respecting its indispensable role in the NHIP, \ Ve hereby
acknowledge he power and authority of Ph.il.Health to do the following:
46. After due process and in accordance \vith the p ertinent provisions of R.A. 7875 and its IRR,
to sus pen , shorten, pre-termmate and/ or revoke our privilege of participating in the NHIP
inciuding h e appurtenant benefits and opportunities at any time during the validity of the
commitm ·nt for any 'r:iolarion of any provision of this Performance Commitment and of
R.A. 7875 and its IRR.
47. After du process and in accordance with the p ertinent provisions ofR.A. 7875 and its IRR,
to suspen , shorten, pre-terminate and/ or revoke our accreditation including the
appunena 1t benefits and opportunities incident thereto at any time during the term of the
comm itm m due to verified t~dvcrse reports/ findings of pattern or any other similar
incidents vhich m ay be inclicative of any illegal, irregular or improper and/ or unethical
conduct o- our operations.
We commit to ex end our full support in sharing PhilHealth's vision in achieving this noble
o bjective o f provi ing accessible quality health insurance coverage for all Filipinos.
Very truly yo'..lrs,

Head ofF acility /Medical Director/

Chief of Hospital

~th my express onfonr'jty,

~

a:
W )-
~~
iii Local Chief Executive/ HCI Owner

~~ 0
a
SUBJECT Revised Performance Commitment for HCI

Page 6 of 6 of Annex B
 Letterhead of the Referral Facility Annex C

CERTIFICATION OF SERVICE DELIVERY SUPPORT

(Inpatient Care)

This is to certify that our facility is PhilHealth accredited and is the referral facility and/ or service
provider in beh lf of (Name of referring facility) for the COVID-19 Home Isolation Benefit
Package (CHIB ) from (period of engagement). As a service partner, we shall provide the
following servic s:

Hospit

0 Management of patient needing inpatient care including laboratory and diagnostic

services J as needed)

0 Conduc on of patient from home to hospital and vice versa, and as necessary

Furthex, this facl ty shall not charge any fees direccly from the referred patient

This cextificatio] is being issued for PhilHealth accreditation and monitoring purposes.

CERTIFIED Bl CONCURRED BY:

Referral Facility I Referring Facility

Medical Directof; Administrative Officer Medical Director/ Administrative Officer

(Signature over , rinted name and designation) (Signature over printed name and designation)

Date Signed: - +--- - - - Date Signed: _ _ _ _ __

Page 1 of 1 of Annex C
 Letterhead of the Referral Facility AnnexD

ERTIFICATION OF SERVICE DELIVERY SUPPORT

(Telemedicine)

This is to cerci that our facility is PhilHealth accredited and is the referral facility and/ or
service provide in behalf of ~ame of referring facility) for the COVID-19 Home Isolation
Benefit Package (CHIBP) from (period of engagement). As a service partner, we shall provide of
the following se ices:

0 f ideoconferencing

0 telephony

0 relereferral

Further, this fac~ty shall while ensuring strict compliance to the data privacy law and shall not
charge any fee ~ direcdy from the referred patient but shall create billing and payment
arrangement witp ~ame of referring facility) for services provided.

This certificatio is being issued for PhilHealth accreditation and monitoring purposes.

CERTIFIED B ,.r: CONCURRED BY:

Referral Facility Referring Facility

Medical Directo / Administrative Officer Medical Director/ Administrative Officer

(Signature over printed name and designation) (Signature over printed name and designation)

Date Signed: --1r--- - - Date Signed: _ _ _ _ __

Page 1 of 1 of Annex D
 Annex E

Authorization for Use of eClaims System

This is to autho ze ~arne of the accredited PhilHealth facility) to use our eClaims system for the
filing and submis ion of COVID-19 Home Isolation Benefit Package (CHIBP) claims using its own
PhilHealth A cere , ·tation Number (PAN) and cipher key. Further, all PhilHealth reimbursements for
the CHIBP's file claims shall be credited to the (name of partner facility) Auto-Credit Payment
Scheme (ACPS) ccount and shall subsequently be disbursed to the said accredited facility based on
agreed terms.

For this purpose, I hereby submit the following bank account information:

1. Bank NaJ e
2. Branch
3. Bank Ace unt Name
4. Bank Ac.cf unt Number
5. Official ~CI Email Address _ _ _ _ _ _ _ _ _ _ _ __
6. Landline Number
7. Mobile N ~mber

(Partner Facilitvl
Signature over pr nted name
Medical Director Authorized Representative

Date signed
-....
N
\~

I
Page 1 of 1 of Annex E
 Annex F: COVII -19 Home Isolation Benefit Package Services

Ma datory Service Other Services

a. Minimum 1p-day home isolation a. Patient Education

consultatior ' • How to use pulse oximeter
• Physici n consultation, at least twice • Signs and symptoms to watch out for
for the uration of isolation; initial
• Proper doses and when to use drugs
consul~ust be done face-to-face and medicines
• Succee · g consultation may be done • Waste disposal and infection control
face-to- ace or through
telecon ultation**
• Others as needed
b. Patient referral to a higher level facility and
b. 24/7 daily 1 p.onitoring of clinical and patient support while for transfer
supportive ' are by a nurse may be done
through tel consultation***
c. Provision o , home isolation kit which
contains: 1 70% alcohol, 5 pieces face
mask, 1 the mometer, 1 pulse oximeter,
drugs and r edicines (18 pieces
Paracetamo , 12 pieces Lagundi tablets or
equivalent, p sachets oral rehydration
salts, 10 pier s Ascorbic Acid, 10 pieces

K)f *
Vitamin D nd zinc), consent form
(Annex

*Except in case ~ transfer due to deterioration

or mortality and ·ased on discharge criteria
from applicable g ll.idelines adopted by DOH.

**In case of telec nsultation, the patient shall

r
be required to sig a Consent Form and shall
be submitted to I hilHealth as additional claim
requirement. (see Annex K)

***Teleconsultati pns may be done through any

of the following: elephone call, cellphone or
internet using M( psenger, Viber, Zoom and
other application .

****Home Isolat on Kit shall be provided to

the patient durin1 initial consult.

..........._Based on currelljtly acceptable gUldelines and other refe~ences rncl~ding. .

.---__.,~·--i' Departmenlt of Health (DM 2020-0512:
{t Revtsed Omrubus Intenm Guidelines on
p,evcntion D etection, Isolation, T'eatment, and Reintegration Strategies for COVID-19

a: 4li
LU >- "ro
...... ll... (i.:l

~~ Page 1 of 1 of Annex F
~
0
0
Annex G: Packa! e Rate and Rules on Co-pay

a. The applic ble package code shall be encoded in the item 9 in CF2.

Package ~ode D escription

C19HI COVID-19 Home Isolation Benefit
Package
Table 1: A !>plicable Package Code

b. The ICD 0 Code in filing for COVID-19 claims shall be in accordance with World Health
Organizati Dn (WHO) and DOH guidelines. Any further changes by the DOH in the
applicable odes shall take precedence and shall be adopted accordingly by PhilHealth. The
applicable CD10 code shall be encoded in the item 7 in CF2.
ICD-10 (ode D escrip tion
"U07 .1" COVID-19 Confirmed
"Z29 .0" Isolation
Table 2: Applicable ICD-10 codes per DOH DM No. 2020-0067

c. The corresponding reimbursement rate is Php 5,91 7.00 per claim.

d. The reimb rsement for government health care facilities shall be utilized to cover all services
and medic· nes provided for in this .benefit package and other operating expenses to support
delivery o care, including hiring ··Of additional personne~ internet subscription, senrice
provider s ,1bscription fee and IT hardware. Any rem~g fund may be utilized for
incentives, ~dueling hazard pay, for human resource involved in its operation with sharing
based on ir temal guidelines.

e. For privat health care facilities, reimbursements shall be utilized at their discretion,
provided tl at this shall also be used to cover for incentives, including hazard pay, for human
resource m olved in its operation, and other costs of delivering the serv1.ces.

f. Patients sh ·ll shoulder payment for services not included in the package.

Page 1 of 1 of Annex G
 Annex H

ASSESSMENT C ECKLIST OF CLINICAL AND SOCIAL CRITERIA FOR COVID-19 HOME

ISOLATION BENEFIT PACKAGE
Name of Patient: I Age: _ _ _ _ __ _ __
Swab T est Result: I D ate Done:
Tes ting Laboratory: - - 1--- - - - -
Panuto: Lagyan ng tsek .tpark 0 ang kahon sa tabi ng iyong obserbasyon at rekomendasyon ayon sa mga kasagutan ng
pasyenteng ineevaluate. Sliliguraduhing lahat ng kahon ay napunan ng tama at ang mga rekomendasyon ay ayon sa mga
panuntunan na nakasulat . ababa.

A. Clinical Evaluation
Part 1. Signs and sy nptoms
• Fever 0 Y es 0 No • Shortness o f breath 0 Yes 0 No
• Cough 0 Yes 0 No • Chest pain 0 Yes 0 No
• Cold s 0 Yes 0 No • Diarrhea 0 Yes 0 No
• Muscle pain D Yes 0 No • L oss of taste/ smell 0 Yes 0 No
• Body weakness D Yes D No

Tandaan: Kapag ang parien ay may shortness of breath, chest pain o iba pang sintomas ng malubhang COVID-19, wag nang
ipagpatuloy ang checklist at i ekomendang magpakonsulta sa doktor

Part 2. History of~ess/Health risk factors

• Immune suppre $sed (katulad ng HIV, cancer and Tuberculosis) 0 Yes 0 No
• May mga risk fa ' tors sa malubhang COVID-19 (obesity, > 60 years of age, 0 Yes 0 No
pregnancy, smo er)
• May m ga comor pidities (katulad ng hyper tension, heart disease, diabetes and 0 Yes 0 No
chronic kidney I ung disease)
• N angangailang~t ng suppor tive care (katulad ng oxygen, antibiotics, intravenous D Yes D No
hydration)

Tandaan: Kapag Yes sa dJlawa o higit pa, ang patient ay hindi maaaring i-home isolate. Kapag Yes sa isa, ikonsulta sa doctor kung
maaanng mag home tsolauJ n. Kapag No sa lahar, ang patient ay clinically eligible for home isolation at magpatuloy sa Soctal Critena
Evaluation. I
Clinically eligible for H p m e I solation 0 Yes 0 No

B. ~
..9 i ·I criteria Evalul tio n
~ 1. May sariling kwkr to D Yes 0 No
- 2. May sariling bar yo/ toilet 0 Yes 0 No
ffi >- ~3 May sapat na aiJ flow/ventilation
I- Q_ o 4 May tagapangal ga o kakayanan rna-meet ang pang-
D Yes 0 No
D Yes 0 No
U?Q ~ araw-araw na p ngangailangan
~ (.) ~ May sariling lan< line, cellphone, o laptop na maaaring D Yes 0 No
magamit para sa teleconsultation
~
Tan a n: Kapag ang patient ay may kahit isang sagot na "no" sa soctal criteria evaluation, ang patient ay hindi maaaring i-home
lSO~e.
---+---J
Socially eligible for Horpe Isolation 0 Yes 0 No

.I
T and aan:
(1) Kapag na-meet ng patien parehas and social at clinical criteria, sila ay m aaring i-home isolate.
(2) Kapag naman na-meet ni a ang clinical criteria lamang, sila ay dapat i-isolate sa isang TTMF / CIU.

R ecommended for: 0 Home I solation 0 TTMF / CIU 0 Magpakonsulta sa

d o h."i:or
Assessed by:
Name wit signature and designation

Page 1 of 1 of Annex H
a. Duly si ed Claim Signature Form (CSF);
b. Copy of he positive RT-PCR result;
c. Duly Sig ed Clearance from the Assessment Checklist of Clinical and Social Criteria for
COVID 19 Home Isolation Benefit Package (Annex H);
d. Duly Si , ed Certification of COVID-19 Home Isolation I<it Issuance (Annex J) or a duly
signed a owledg.ement receipt;
e. Signed thorization and Consent to Participate in Teleconsultation (Annex K)
f. Accomp ·shed monitoring sheet signed by the home isolation team (Annex L)

u
0

Page I of I of Annex I
AnnexJ

Certification of COVID-19 Home Isolation Kit Issuance

This is to acknowledge eceipt of the COVID-19 Homecare kit.

0 1L 70% Alcohol D Drugs and medication

0 5 pieces Face Mas D 18 pes Paracetamol (500 mg)
0 1 unit Pulse Oxim ter D 12 pes Lagundi Tablets or equivalent
D 1 unit Digital TheE l ometer D 6 sachets ORS
D Authorization and Consent to D 10 pes Ascorbic Acid
Participate in Tele onsultation D 10 pes. Vitamin D
D Zinc

(Signature over Printed ame of Patient and Date)

PhilHealth Identifi.catio No. (PIN): _ _ _ _ _ __

COVID-19 Home Isoll tion Kit Issued by: Signature over printed name

Date~='------------l-

Page 1 of 1 of Annex J
Annex K

TION AND CONSENT TO PARTICIPATE IN TELEMEDICINE CONSULTATION

The purpose of this for is to obtain your consent to participate in a telemedicine consultation with the following physician:

Purpose and Benefits. Tl e purpose of this service is to use telemedicine to enable patients to still receive health services even while
staying at home during th enhanced community quarantine, except for serious conditions, emergencies, or ro avail of COVID-19-
related health services as pe standing protocols.

Nature ofT elemedicine onsultation: During the telemedicine consultation:

a) Details of you an4/ or the patient's medical history, examinations, x-rays, and tests will be collected and discussed with other
health profession1 s through the use of interactive video, audio and telecommunications technology if needed.
b) Physical examinaf· n of you or the patient may take place.
C) Nonmedical teclu ·cal personnel may be present in the telemedicine studio to aid in video transmission, if needed.
d) Video, audio, and or digital photo may be recorded during the telemedicine consultation visit.

Medical Information an Records. All existing laws regarding your access to medical information and copies of your medical
records apply to this telem dicine consultation. Additionally, dissemination of any patient identifiable images or information from this
telemedicine interaction to esearchers or other entities shall not occur without your consent, unless authorized by existing law, policies
and guidelines on privacy a d data protection.

Confidentiality. Reasonab e and appropriate efforts have been made to eliminate any confidentiality risks associated with the
telemedicine consultation. rganizational, physical and technical security measures are in place to ensure that all information processed
during the consultation will emain confidential and only authorized personnel will have access to such information on a need-to-know
basis. All existing laws, poli ies and guidelines on privacy and data protection apply to information disclosed during this telemedicine
consultation.

Potential Risks and Cons quences. The telemedicine consultation will be similar to a routine medical office visit, except interactive
video technology will allow you to communicate with a physician at a distance. At fust you may find it difficult or uncomfortable to
communicate using video · ages. The use of video technology to deliver healthcare and educational ser.vices is a new technology and
may not be equivalent to di ject patient to physician contact. As any medical procedure, there may be potential risks associated with the
use of this technology. These risks may include, but may not be l.i.!l"lited to:

a. Information transmi ted may not be sufficient to allow for a conclusive consultation by specialist. Following the telemedicine
consultation, your p 'Sician may recommend a visit to a health facility for further evaluation.
b. D elays i11 medical ev luation and treatmen t could occur due to deficiencies or failures of the equipment.
Security protocols ould fail, causing a breach of privacy of my confidential medical information.
c. A lack of access to c mplete medical records may result in errors in medical judgement.
d. There is no guarante that this tete-consultation will eliminate the need for me to see a specialist in person.

Rights. You may withhold r withdraw consent to the telemedicine consultation at any time without affecting your right of future care
or treatment, or risking the oss or withdrawal of any program benefits to which you would otherwise be entitled. You have the option
to consult with the physicia in person if you travel to his or her location.

Financial Agreement. Yo and/ or your insurance company will not be billed for this "i.sit.

I have been advised of a the potential risks, consequences and benefits of telemedicine. The physician of this telemedicine
consultation has discussed' "th me the information provided above. I have had an opportunity to ask questions about this information
and all of my questions hav been answered. I understand the written information provided above.

Signature:

Date:_ _ __

~
Patient (or pers n authorized to give consent)

If signed by person other --~~-::-i-~-t--

an patient, provide relationship to patient: -+--r.......

tb>- ~ Date:_ _ __

iB~
Witness:-- - - -- - - + - -- - - - -- -- - - - --

Page 1 of 1 of Annex K

(.)
0
 Annex l: _Home Isolatfon Patient Monitoring Sheet
Confirmed Case ID: _ Date :___}__)_ __ Region: _ _ _ __ __ _ __ _
Patient Name · I
Date of Exposure: _ __) End of Quarantin e Period Date: __j__)

Instructions: Monitorin~ should be done twice a day; once in the morning and once in the afternoon/even ing.
Indicat e th e date and g , through each item. Put a check if a patient has the symptom upon monitoring in the
correct column (AM/PM and indicate temperature taken (ie . 38C).

Day Day Day Day Day Day Day Day Day Day Day Day Day Day
1 . 2 3 4 5 6 7 8 9 10 "11 12 13 14
Date:
AM
Temp
PM
AM
Oxygen
PM
Cough (ubo)
Chills (panginginig)
Fatigue/Tiredness
(pagkapagod)
Body pain (Sakit ng
Katawan)
Headache (Sakit ng
Ulo)
Loss of Taste and Smell
(Pagkawala o bawas ng
panlasa o panga moy)
Sore Throat (masakit
ang lalamunan)
Congestion or runny
nose (Sipon na nakabara
o tumutulo)
Dia rrhea (Basa o labis
ang pagdudumi)
Nausea/Vomiting
(Naduduwal o
nagsusuka)
Red lags (magreport agad kung maranasan ang sumusunod na 'sintomas) .
Shortness of Breath or
Difficulty in Breath ing
(Hirap sa paghinga)
Persiste nt Pain or
Pressure in th e Chest
(sakit o bigat sa dibdib
na di nawawala)
Confusion
(Biglang pagkalito) -....
Difficulty in waking up or 2:
slee ping (hirap matulog ~
o magising)
n-=
~
Pale, gray, or bluish lips IUD
or nailbeds (pagbabago
ng kul ay ng balat, labi, o rE>-
t-a..
,_
Cl
«i
ro
kuko) ~
.~o
~
Others (!bang sintomas):
1.
2.
3. ,; ..;
a
Assessed and monitored py:
-
Doctor[Nurse of the Home Isolation Team
Printed Name and Signa 1 re Page 1 of 1 of Annex L
Designation