Republic of the Philippines

PHILIPPINE HEALTH INSURANCE CORPORATION

Citystate Centre Building, 709 Shaw Boulevard, Pasig City
Healthline: 441-7444 Website: www.philhealth.gov.ph

Date & Time of Generation :

HCI Portal Reference No. :

JULY
16, 2015 02:07:36
BEF100000004935604

_________________________________________________________________________________
HEALTH CARE INSTITUTION (HCI) INFORMATION
Name of Institution :
DITSA-AN RAMAIN RHU
Accreditation No. :
M14013518

_________________________________________________________________________________
MEMBER INFORMATION
PhilHealth Identification No. : 230031704257
Name of Member :
ABRAR , TAMMY BANDERA
Sex :
MALE
Date of Birth :
JANUARY 12, 1975
Member Category :
INDIGENT

_________________________________________________________________________________
PATIENT INFORMATION
Name of Patient :
Date Admitted :
Date Discharged :
Sex :
Date of Birth :

MADALE , MONALYNDAO MANGOTARA

MAY
29, 2015
MAY
30, 2015
FEMALE
SEPTEMBER 03, 1976

_________________________________________________________________________________
ELIGIBILITY INFORMATION
ELIGIBLE TO AVAIL PHILHEALTH BENEFITS? = YES

Reason/s:
undefined
_________________________________________________________________________________

Attached Documents:
N/A

_________________________________________________________________________________
Important Reminders:
1. Generation and printing of this form is FREE for all PhilHealth Beneficiaries.
2. This form shall be submitted along with the required PhilHealth claims forms and is valid only for the confinement/admission stated above.
3. This does not include eligibility to the rule of SINGLE PERIOD OF CONFINEMENT(SPC). It shall be established when the claim is processed by PhilHealth.
Non-qualification to the rule on SPCshall result to denial of this claim.

_________________________________________________________________________________