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 : MARCH 04, 2019 10:19:17 PM

HCI Portal Reference No. : BEF100000034978773
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HEALTH CARE INSTITUTION (HCI) INFORMATION
Name of Institution : BATAAN GENERAL HOSPITAL AND MEDICAL CENTER
Accreditation No. : H03002628
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MEMBER INFORMATION
PhilHealth Identification No. : 070257574596
Name of Member : MENDOZA , AHRMHEL DALE CANARE
Sex : MALE
Date of Birth : MAY 17, 1994
Member Category : FORMAL ECONOMY - PRIVATE - PERMANENT/REGULAR
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PATIENT INFORMATION
Name of Patient : MENDOZA , AHRMHEL DALE CANARE
Date Admitted : MARCH 04, 2019
Sex : MALE
Date of Birth : MAY 17, 1994
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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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