The PhilHealth Premium Payment Slip is currently being used by accredited collecting agents. The employer/member would need to fill-out the slip, present the slip and the payment to the agent. You should ensure that the slip is properly filled-out as the details you have reflected will be recorded in PhilHealth's database.
To avoid the long lines and ensure availability of the form, PhilHealth is now allowing access to the form in softcopy format. You may download the PhilHealth Premium Payment Slip here.