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: pif te pine -@ 4 , PHILIPPINE HEALYH INSURANCE CORPORATION gaPbilteatth CallCemer 2) 7042 Wann 2) Naren nd vnephiheth goer ci: concentric goeph ed Sepember 2016 IMPORTANT REMINDERS: PLEASE WRITE ING LaTTRRS ND CHECK: SPRIATE BOXES. ses TT TET TTT} Fas nconsect W-ORAION Ot MSREPRESENTATON SLL SUBJECT To CRIMINAL Ci OF EMNMERATNE LAB 1.PhilHealth identification Number (PIN) of Member: ae) DEEL a 2.Name of Member: = 3. Member Date of Birth: CalTeio itilice —__ ai ie Klee We e-G-e ‘nati deietin tandem ofDeendene: [T-CELELEE I ™EBETEL). QW cARL ss REcune som ee cl 7.Confinement Period: 8.Patient Date of Birth: (S)-0B1-T wovemet PTO}-(T9}-fol 14) 710} - (271-2017 9. CERTIFICATION OF MEMBER: Ander he pent Tp 7 : (o-O R210) : the formation | provided in thi Farm ar true and accurate tothe bestof my knowledge Coo CAéroeer Trae aay ey COTATI OOIOro) 2.contactno: 0916 Y2§ 34 3.Business ame: DEP ED _ phi beer 4, CERTIFICATION OF EMPLOYER: rn to erty thot he required so monty premium contribution plus ot least 6 months contributions preceding the 3 months qualifying contributions within 22 ‘month period por tothe rst dy ofGoninement afclent regulary) Rove been regulary rented te Phleath Moreover, the formation supped bythe member or ther representative rastoewith our avolble records” — miso Ap pwz 2 PRP RAY | vse TD) 1-210 “hereby consent to the submission and examination ofthe pagent pertinent medical records forthe purpose of eying the veracity ofthis claim to eect efficint procesingo benef poy Ha payment. Thereby hold Phitetin or any of its of «dior representothes re trom ony legal ables relative othe heein-menvoned consent which Rave ‘volun end wing geen ny ‘um for remburcement before Pulcath ‘ spac ae oe Sa STE) sane CASA _— oo Sere Over Printer Name EEE a Fn crwestedes “1. teens EMO a rd Cale, nthe point’ chert and heath creinstnon cord ta the erin oration gen net ond core. Me, eo

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