MEDICAL ASSISTANCE APPROVAL FORM

QUALIFICATION

COMPANY:
NAME:
DATE OF MEMBERSHIP:
POSITION: LAST CONTRIBUTION:

PATIENT: Employee Dependent: Relationship ___________________

EMPLOYEE: Single Married

TYPE OF ILLNESS: MAJOR DREADED OUT PATIENT EMERGENCY (UP to 1,500.00)

AVAILMENT: Employee: 1st 2nd

Dependent: 1st

FOR COMMITTEE APPROVAL

COMMITTEE MEMBERS/ APPROVED DATE REMARKS

REPRESENTATIVES

AFC - AZENITH S. CABRERA _______________ _____________ _____________

GDFI - NANETTE G. TURINGAN _______________ _____________ _____________

ACMSI - CHERILYN B. PANGANIBAN _______________ _____________ _____________

FMCMI - RUBEN B. LOPEZ _______________ _____________ _____________

FFCC/ALFC – JENNIFER A. ROBEL _______________ _____________ _____________

__________________________ _______________ _____________ _____________

6TH Committee Member

EILLEN B. MANGUBAT ________________ _____________ _____________

RECOMMENDED BY: __________________________

GM/REPRESENTATIVE FROM
EMPLOYEE’S COMPANY