TrueMed – PhilHealth YAKAP GAMOT Availment Form

Last Name*

Last name is required.

First Name*

First name is required.

Company or Group

By submitting this form, I authorize TrueMed to process my personal health information and prescription documents for the purpose of medicine delivery and PhilHealth benefits facilitation. I confirm that all documents uploaded are authentic and accurate. I understand that my data will be handled in accordance with the Data Privacy Act of 2012 (R.A. 10173) and will not be shared with unauthorized third parties. I also give TrueMed consent to send me notifications, updates, and messages moving forward regarding my submission, delivery, account, and other relevant healthcare-related or service-related communications.

Agreement is required to continue.

UPSC Code*

UPSC code is required.

Prescription Photo*

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Tap to choose file

Issued by a licensed physician · PDF, JPG or PNG

Prescription photo is required.

ID Type*

Select an ID type.

Upload Valid ID*

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Tap to choose file

JPG, PNG or PDF · both sides if applicable

A valid ID is required.

Sign below*

Draw your signature here

Signature is required.

Contact Number*

Enter a valid contact number.

Street Address*

Street address is required.

City*

City is required.

ZIP Code*

ZIP code is required.

Region*

Select a region.

Landmark

Delivery Notes

Availment Form

Documents Submitted