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PCA Appform PDF

This document is an application form for accreditation as a collecting agent of the Philippine Health Insurance Corporation (PhilHealth). It requests background information on the applying company such as its name, address, contact details, nature of business, years in operation, affiliations, and number of branches. It also asks the applicant to specify which collection methods they propose to use for both local and overseas collection of PhilHealth payments, whether manual over-the-counter, manual reporting, online collection, or online reporting.

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103 views1 page

PCA Appform PDF

This document is an application form for accreditation as a collecting agent of the Philippine Health Insurance Corporation (PhilHealth). It requests background information on the applying company such as its name, address, contact details, nature of business, years in operation, affiliations, and number of branches. It also asks the applicant to specify which collection methods they propose to use for both local and overseas collection of PhilHealth payments, whether manual over-the-counter, manual reporting, online collection, or online reporting.

Uploaded by

elka priela
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Republic of the Philippines

PHILIPPINE HEALTH INSURANCE CORPORATION


Citystate Centre, 709 Shaw Boulevard, Pasig City
Healthline 637-9999 www.philhealth.gov.ph

FORM 1

PHILHEALTH COLLECTING AGENTS ACCREDITATION COMMITTEE

APPLICATION FORM

Application No.___________

BACKGROUND

COMPANY NAME: _____________________________a.k.a:_________________

Business Address: ______________________________________________________

Telephone No: _________________________ Fax No.:________________________

Email Address: ________________________

Head of Agency: ____________________________________________

Nature of Business: _______________________

No. of years in the business: ________________

Affiliation if any: _________________________

Number of branches: Local: _____________________


Overseas: __________________

PROPOSAL

Local Collection Overseas Collection

Manual Over-the-Counter Manual Over-the-Counter


Collection/ Manual Reporting Collection/ Manual Reporting
Manual Over-the-Counter Manual Over-the-Counter
Collection/ On-Line Reporting Collection/ On-line Reporting
On-Line Collection / On-Line Collection /
On-Line Reporting On-line Reporting

Received by: Date:

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