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. :

AUGUST 18, 2015 02:08:53

BEF100000005484763

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

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MEMBER INFORMATION
PhilHealth Identification No. : 230031695894
Name of Member :
SANTOS , MUHAYMEN ABUS
Sex :
MALE
Date of Birth :
DECEMBER 11, 1982
Member Category :
INDIGENT

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

SANTOS , AMOR APOK

JULY
19, 2015
JULY
20, 2015
FEMALE
APRIL 17, 1983

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ELIGIBILITY INFORMATION
ELIGIBLE TO AVAIL PHILHEALTH BENEFITS? = YES

Reason/s:
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Attached Documents:
N/A

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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.

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