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Republic of the Philippines

PHILIPPINE HEALTH INSURANCE CORPORATION


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

Bawat Pilipino Miyembro, Bawal Miyembro Protektado, Kalusugan Natin Sigurado

Date & Time of Generation : May 10, 2018 10:12:46 AM


CEWS Tracking Number : 2801-0218-0500-2457

HEALTH CARE INSTITUTION (HCI) INFORMATION

Name of Institution : UP-PHILIPPINE GENERAL HOSPITAL


Accreditation No. : H91005030

MEMBER INFORMATION

PhilHealth Identification No. : 010262522313


Name of Member : MAY MALINIS LOBRIGO
Sex : Female
Date of Birth : April 22, 1999
Member Category : Individual Paying

PATIENT INFORMATION
Name of Patient : MAY MALINIS LOBRIGO
Date Admitted : May 09, 2018
Sex : Female
Date of Birth : April 22, 1999

ELIGIBILITY INFORMATION
ELIGIBLE TO AVAIL PHILHEALTH BENEFITS? = YES

DOCUMENTS TO BE SUBMITTED TO PHILHEALTH

Important Reminders:
1. Generation and printing of this form is FREE for all PhilHealth Beneficiaries.
2. If the Electronic Claims Submission is not yet implemented, 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 CONFINEMENT (SPC). It shall be established when the claim is processed by PhilHealth.
Non-qualification to the rule of SPC shall result to denial of this claim.
4. *Corresponds only to the paid claim as of the date and time of generation. PhilHealth Benefit Claims that are in transit or on process are not yet included.

Member / Representative Module 1 CEWS User


Signature Over Printed Name / Thumbmark Signature Over Printed Name

Philippine Health Insurance Corporation


Citystate Center, 709 Shaw Boulevard, Pasig City. HealthLine: 441-7444