iy PhilHealth CSF (chim sgatare UwPORTANT REMINDERS: ram betel Sates Ftconais ented ba kane semney onscreen aon i et SS neous ceo co ceResaSeuraiN a. Be SLANT SIN, Sk AIST LABRITES FART T>WEMBER ANG PATIENT NFORMATION AND CERTIFICATION 1, Preah eifcaton Number PN ofMenbe- LIA = 2 3 ee One ELINDE te O-O5- ud ae Castner Fesinare Nise Name raga Oa Gu. Jn J, Sg) erates sara 4 rte : cameapine cious L ‘First Name ‘Middle Name (example: Dea Cruz, Juan J. Sipag) Voom Pat poe er Crate 0) L-com oman LL) sreton son .--ai i Us Ue Ua B5-0¢ romeo! (i oy a pelt pans vm ef eer keri =a (ete iiaialiee ae ee Bow me ee a enters epee 1 Pht Erp No. PEN: iu LJ 2 cone 5. Business Nae |. CERTIFICATION OF EMPLOYER: This isto certify that all monthly premium contbutions fr ad in behalf ofthe member, while employed inthis company, including the snplicabe thre (3) monthly premium contributions within the past six (6) months period pier tothe fist day af this confinement, have been deductedicolected and remitted to Phltielth, and that the information supplied by the member or hither representative on Part! are consistont with our availabe records. “Traine Ore Pied tore decors [ation Repeeeiaie —_— Oficial Gapacly Oeagraton— hole bus {ers consetto the examination y Prieto te patents medial record forte pup of elying the aac of his lm, ‘ery at Pint ray of fcr, employes sar eresentatve re hom ana al abies eee hr nated consent sd logy ven in conncton wth hs nfo reinbureert fir PPeath, lana! So a Srestendaves ee oo Lal Parent “Apaten reeesentatve swale tte, — Sing Others. spec, ‘inna ate reine eo ond fecstetrsum Foion eases Sbreiescnue Stroma ie ie Ouenenms Peet Repeat—[——SEEE—E Ee a - =a a : = a a OT bt-bd-Li bbb) Ba pst beers) Bat aT Neer. aad baal el Span Ow Pane bal- Ud - aie Se cer PARTY a oo ia Rae gr RES ot “eY —_ FO OE alt