.
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.1 Annex "B"
Series No. Oate
E- PHILHEALTH ONLINE ACCESS FORM
eOaF Form No. oo1. Aug6t 2012
ReviseO
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Name of Employer PhilHealth Employer Number (PEN)
A
fq *
Business Address Philippine Standard and Division Code Station Code
ceographic Coding (PSGC)
Position Email Address Telephone No./Mobile No.
Name and Signature of Head of Orrice
d* .&* * d*
Name of Philhealth Employers Engagement Positionof PEER EmailAddress Mobile Number
a -$*.
Representative (PEER)
PEER Company/Agency No. Telephone No.
To be Iilled-out by PhilHeolth
Begistration Date Regional / Branch office LHIO Orientation Date
Processed Date Processed By System to be Accessed Role Assigned
Anner "A"
L tv PHILHEALTH EMPLOYERS' ENGAGEMTNT No.
" RrpnrsENTATIVE(FEIn)
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INFORMATION SHEET
lfnn{ry) lrldr N!mof {Mlddb niml {3ulfh}
Name
Mailing Address
Email Address Celphone No.:
Oate of Birth tlErsl {D,tl (Y6.4
Telephone No.:
Positlon fltle: tax No,l
PhilHoalth ldentlflcotion Number{PlNl:
Ftlrl)t f.lYFtt I N rnntlrt Attrlr.t
Narne of
Company/Agency
Hord nf
Oflice/Owner
Mailing Address
Fmpil ArJdrocc I
I
PhllHealth [mployer NumberlP€r{l
ADDITIONAL ID INFORMATION
lXllDPicture
ln case of emergency, contact:
Relationship: Contact Numbers:
{Signatrlre ovpr
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L.L of tha Fhlllpplnes
Republlc
PHI LI PPI N E HEALTH If'ISU RAfiICE CORPORATIOI{
NNNEX'8"
Cltystate C€ntre Bulldlng; 709 Shaw Boulev.rd, Pasig Crty
*l::i Healthline 441-7aal yyS0ry,Bhilb-qe1ll}aaY,ph
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r{oN.0tsclo$uRE AGREEMEI{T
Should you be identilied as a PhilHoalth Employefs Engagement Representalfue (PEER), please be informed
that:
Employer and employee.member inrormaUon from any sourcs and in any form (i.e, writlen, verbalor electronic)
is confidential. Access to these pieces of informalion is allowed ONLY if it is needed for you to effectively and
effichntly perform yourlasks as a PEER.
ln the course of the performance of your tasks as a PEER, you may come across conlidential information about:
information, salaries, employment records, oomplainb, benelit availment, and lhe like)
Do you agree to:
/ PROfECT the privacy of your employer, employee-member$ and other stakeholders at all times?
./ ONLY access the information needed to etfectively and effrciently discharge your tasks as a PEER?
r' NOT misuse or be imprudent with conridential infonnation?
./ ENSURE that documents containing confidential information ara disposed, if needed, properly in the manner
lhat will prreclude olhers kom knowing sueh confidenlial informalion?
/ KEEP your usernarne and password secret and not sharc these pieces of informalion to anyone?
r' NOf use us€mama and passrordotherthan my own in accessing any PhilHealth lnformation System?
,/ Be RESPONSIBLE for the use or misuse of confidential information?
/ NOT make any unaulhorized copies of PhilHealth's data, sta$stics, and other related information?
/ NOT share any conlidential information even if you are no longer connected with the employer who identitied
you as its PEER?
./ REPORT any unauthorized use or disclosure of confdenfial health information?
YES NO
I fully understand lhe concepls rogarding confidenliality and privacy of confidential hoalth information. ln
addilion, I also know and agree that my failure to lullill any ol the agreernenls sel forth in thls Agreoment and/or
my violations of any tenns of lhioAgreement shall result in my being subject to appropriate disciplinary and/or
legaf action. ' ,
Signature: Oate Signed:
Full name in print:
Name of Agency/Corporation:
Narne and Signature of lmmediate Supedor Date signed:
t,*
l#1.* r'!liLirr.4Lt-i
lri'iidrcata: i. : .';::i ,'_ (:\;1,
Phltlealth Regbnat Olfico
PhilHiolth Enpby8r's f rBagoment Rapr8santatys (PEER)
i;7r:r, til'l.ids "lb
t",,"
lmmediab Suporior ol lhe PEER
" , , l:-: f',-! !li-.
. -. \,1-.r. I
tcamphilhealth ilt J www.fnr:sbrxrk.cun/lrhil].Icalth CP info@otilhenlrh.pov.ph
