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PhilHealth Record Correction Affidavit

Juan Dela Cruz files an affidavit to correct discrepancies in his Philippine Health Insurance Corporation (Philhealth) Member Data Record (MDR). Specifically, his MDR incorrectly lists his first name as something other than "Juan" and his year of birth as something other than January 1, 1900. He attaches a copy of his birth certificate and BIR TIN ID to support the corrections.

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Anna May Oliveros
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110 views1 page

PhilHealth Record Correction Affidavit

Juan Dela Cruz files an affidavit to correct discrepancies in his Philippine Health Insurance Corporation (Philhealth) Member Data Record (MDR). Specifically, his MDR incorrectly lists his first name as something other than "Juan" and his year of birth as something other than January 1, 1900. He attaches a copy of his birth certificate and BIR TIN ID to support the corrections.

Uploaded by

Anna May Oliveros
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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REPUBLIC OF THE PHILIPPINES )

PASIG CITY ) S.S.


x--------------------------------------------------------x

AFFIDAVIT OF DISCREPANCY

I, JUAN DELA CRUZ, of legal age, a Filipino, and a resident of,


Pinagbuhatan, Pasig City, after having been duly sworn to in accordance with
law do hereby depose and state:

1. That I was born in Tawi-Tawi on January 1, 1900 by my parents Jun Dela


Cruz and Juana Dela Cruz;

2. That on the day I was born, my parents were not married;

3. That my correct first name per my birth certificate with Local Registry No.
00-000 is “JUAN” and my correct year of birth is “January 1, 1900”;

4. That I am attaching in this affidavit a copy of my birth certificate and BIR


TIN ID for reference;

5. That I am executing this Affidavit to inform persons concerned of such


discrepancy in my Philippine Health Insurance Corporation (Philhealth)
Member Data Record (MDR) and for purposes of correcting such
discrepancy;

6. That I am now executing this Affidavit as requested by the Philippine


Health Insurance Corporation, for the purpose of correcting my MDR to
reflect my true and correct name and birth date.

IN WITNESS WHEREOF, I hereby affixed my signature this __________ in


the City of Pasig.

JUAN DELA CRUZ,


Affiant

SUBSCRIBED AND SWORN to before me this _________ in the City of


Pasig. Affiant exhibited to me his________________.

Doc. No.
Page No.
Book no.
Series of

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