ANNEX G: Electronic Konsulta Availment Slip (eKAS)
Electronic Konsulta Availment Slip (eKAS) – proof of availment of services by the eligible beneficiary. This will be
generated by the PhilHealth Konsulta facility for every patient encounter and to be submitted to PhilHealth.
ELECTRONIC KONSULTA AVAILMENT SLIP (eKAS)
HCI Name: ____________________ Case No.: _________________ HCI Accreditation No. __________ Transaction No: _______________
Patient Name (Pangalan ng pasyente):_________________________________ Age (Edad): _________ Contact No. _____________________
PIN (PhilHealth Identification Number): ______________________________ Membership Category: ________________________________
Membership type: ______ Member _______ Dependent Authorization Transaction Code (ATC): _________________________
To be filled out by the facility (pupunuan ng pasilidad)
Performed by
Performed (Ginawa ni)
Date performed
(nagawa) (Initial/Signature of Health
Konsulta Services (Petsa kung kelan
X Not performed care Provider/technician)
ginawa)
(hindi nagawa) (Initial o Lagda ng Health
care Provider/technician)
History and physical examination (vitals, anthropometrics)
CBC
To be filled out by the patient (pupunuan ng pasyente)
Have you received the above-mentioned essential services? __ Yes __ No
(Natanggap mo ba ang mga essential services na nabanggit?)
How satisfied are you with the services provided?
(Gaano ka nasiyahan sa natanggap mong serbisyo?)
For your comment, suggestion or complaint:
(Para sa iyong komento, mungkahi o reklamo)
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Under the penalty of law, I attest that the information I provided in this slip are true and accurate.
(Sa ilalim ng batas, pinatutunayan ko na ang impormasyong ibinigay ko ay totoo at tama)
_______________________________________ Next Consultation Date: ___________________
Signature over printed name of patient (Petsa ng susunod na konsultasyon)
(Lagda sa nakalimbag na pangalan ng pasyente)
Note:
Accomplished form shall be submitted to PhilHealth.
(Ang kumpletong form ay dapat isumite sa PhilHealth)
Page 1 of 2 of Annex G
ANNEX G: Electronic Prescription Slip (ePresS)
Electronic Prescription Slip (ePresS) - proof of availment of medicines by the eligible beneficiary. This will be
generated by the PhilHealth Konsulta facility for every patient encounter and to be submitted to PhilHealth.
HCI Name: ______________________________________ Case No.: __________________________________
HCI Accreditation No. ______________________________ Transaction No: _____________________________
Patient Name (pangalan ng pasyente):____________________________ Age (edad): ________ Contact No. ________________________
PIN (PhilHealth Identification Number):________________ Membership Category: ____________ Membership type: __ Member: __ Dependent
To be filled out by the facility (pupunuan ng pasilidad)
Dispensed
Medicine Date
Name of the Prescribing (naibigay)
Strength/Form/ dispensed Name of the Dispensing
Category Quantity Physician X Not
Volume (Petsa Personnel
(Kategorya) (bilang) (Pangalan ng nagresetang dispensed
(Gamot/Anyo/Da kung kelan (Pangalan ng nagbigay)
doktor) (hindi
mi) naibigay)
naibigay)
Amoxicillin
Antibacterial
500 mg Capsule
Paracetamol Signature over printed name Signature over printed name
Antipyretic
500 mg Tablet License #: _____________ Name of Dispensing
Facility:_______________
To be filled out by the patient (pupunuan ng pasyente)
Did you receive the above mentioned medicines? __ Yes __ No
(Natanggap mo ba ang mga gamot na nabanggit?)
Are you satisfied with the medicines you received?
(Nasiyahan ka ba sa mga gamot na natanggap mo?)
For your comment, suggestion or complaint:
(Para sa iyong komento, mungkahi o reklamo)
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Under the penalty of law, I attest that the information I provided in this slip are true and accurate.
(Sa ilalim ng batas, pinatutunayan ko na ang impormasyong ibinigay ko ay totoo at tama)
_______________________________________ Next Dispensing Date: _____________________
Signature over printed name of patient (Petsa ng susunod na bigay ng gamot)
(Lagda sa nakalimbag na pangalan ng pasyente)
Note:
Accomplished form shall be submitted to PhilHealth.
(Ang kumpletong form ay dapat isumite sa PhilHealth)
Page 2 of 2 of Annex G
