ANNEX A

PHILHEALTH ONLINE ACCESS FORM

(POAF) Form No. 002

NO.

Registration Date

Name of Accredited Institutional Health Care Provider Business Address

PhilHealth Accreditation Number

User Profile
Complete Name Position Approved by: Email address Signature Mobile No. Date Signed

To be filled-out by PhilHealth
Installation Date Username Processed by Approved by Regional / Branch Office Password Signature Signature Date Processed Date Signed Email address

Institutional Confirmation Confirmed by: Medical Director/Administrator/Authorized Representative

Date Confirmed