PHILIPPINE HEALTH INSURANCE CORPORATION ‘oe Pp Ment, ve Mo Pend alg Ne Side Date & Time of Generation : November 27,2018 19:24:42 PM (CEWS Tracking Number 2039-1518-1100-0012 Republica te Pipines ay y HEALTH CARE INSTITUTION (HCI) INFORMATION Name of Insiution : VITAL LYINGAN CLINIC Accreditation No. : 105027296 MEMBER INFORMATION PhileattnIdentication No, sonozasers34 Name of Member Rachel Quinto Bordeos Sex Female Date of ith : tune 10, 1990, Member Category H INFORMAL ECONOMY - INFORMAL SECTOR PATIENT INFORMATION Name of Patient Precious Xia Bordeos Acal Date Admitted November 26, 2018 Sex Female Date of Btn November 26, 2018 ELIGIBILITY INFORMATION ELIGIBLE TO AVAIL PHILHEALTH BENEFITS? = YES DOCUMENTS TO BE SUBMITTED TO PHILHEALTH tmoarant Rennes: 1 Thrcnet nd pene SNGLEPENGDCONFRENENT 62) able eda he i nt Pra z Tenet it f Fade 8 rds ERLINOA Ev ‘Sanat Ove Pra Name Tana ‘Sips ve rts Name ‘Praga Hea psuance Capontion iy Cone 70 Sta Beserard Pan CW Roe: 4-74