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= + Ropublic of he Pipes me 4 PHILIPPINE HEALTH INSURANCE CORPORATION cs F eran onal ich gph (Claim Signature Form) IMPORTANT REMINDERS: *CCTTTTTIT Tit) 7. LETTERS AV CHECK Ti FALSE/INCORRECT INFORMATION OR MISREPRESENTATION SHALL BE SUBJECT TO CRIMINAL, CVILOR ADMINISTRATIVE IABILITI 1PhilHealth identification Number (PIN) of Member: [OXC]- TE 2.Mame of Member: 3.Member Date of Birth: eek 7a ss. _ papa ew FG) 4.PhilHealth identification Number (PIN) of Dependent: [T}-[T TTT 111110) 5.Name of Patient: 6.Relationship to Member: CALIDA 2, = a PMAWANG Zhoii Foner 8.Patient Date of Birth: eevee (53)-S00) 20D) Twa = Ae eh) 9. CERTIFICATION OF MEMBER: Unde te latest thatthe information prvied inthis Frm rt a acarat thebestof ey hota very b.© 6aninag | a TRL mee CLELL RCL Or LPhiltealth Employer Number (PEN): |] -(1 1111111 1-U 2.contact No: 3.Business Name: 4. CERTIFICATION OF EMPLOYER: “This i to certify tat the required 3/6 monthy premium contributions plus at month period prt tthe rst day of confinement suticient regularity) have been Sa ema Seo records no CCD cast 6 months contributions preceding the 3manths quoting contribution within 12 veguorty remitted to Pibtecith Moreover, the information sunpied by the member or Neer nnn cans memetnnng eee ee ae Ft ot otras ten hd inet nrc she Cea aah ne ern a OE ORES oo TD See Osea Oe Age Oh eee (CECE. ee « EEE ECC 1.PhilHeatth Benefits: 4 4 Cane ate 55 signts cart and health care institution records ond thet the herein information given ore true and core gee” Benne Pats mepicat— br