ANNEX A3

PHILIPPINE HEALTH INS0RANCE CORPORATION

M(ni&ip$l He$lt. Offi&e C$l$si$o1 P$n2$sin$n

PC

PATIENT LE"!ER
BHS; ___________________

Rural Health Unit - ___

Part I

NAME OF HEALTH CARE FACILITY

Name: _________________________ Age: ______________ Sex: _______________ Address: ___________________________ PIN: ______________________ ( ) PHIC ( ) Member ( ) De endent ( ) NON PHIC Prim$ry Pre%enti%e Ser%i&es Sponsored ( ) NHTS ( ) NGA ( ) LGU ( ) Pr!vate IPP ( ) OG ( ) O"# Employed ( ) Government ( ) Pr!vate ( ) Lifetime

( ) $o%&ntar'(Se%)*+m %o'ed O LI!ATE" SER#ICES Fre'(en&y

)st *tr

"$te Performed
+nd *tr ,rd *tr -t. *tr

,- .P Meas&rements H' ertens!ve Non*H' ertens!ve 1- Per!od!/ 2%!n!/a% .reast +xam!nat!on 3- $!s&a% Ins e/t!on 4!t0 A/et!/ A/!d

On/e a mont0 On/e a 'ear On/e a 'ear On/e a 'ear

"IA!NOSTIC E/AMINATION SER#ICES Part IDate D!agnos!s T' e G!ven 5e)erred 5emar6s

OTHER PC ) SER#ICES
Date D!agnos!s T' e 5emar6s

OTHER SER#ICES
Date D!agnos!s T' e 5emar6s