JOLLIBEE FOODS CORPORATION

Optical and Outpatient Medicine Reimbursement Form

12/01/2020
(Important: Please fill-out this form and attach the required documents)

Patient/Employee Information
PATIENT'S NAME PAUL JOHN VALENCIA
EMPLOYEE'S NAME PAUL JOHN VALENCIA
EMPLOYEE NUMBER 155990
STORE/DEPARTMENT RBU HR
CONTACT # 09989807445
HOSPITAL/CLINIC RIVERSIDE MEDICAL CENTER
DIAGNOSIS -
TOTAL AMOUNT FOR REIMBURSEMENT 950.00
E-MAIL ADDRESS pauljohn.valencia@jollibee.com.ph
BASIC REQUIREMENTS:
1. Properly accomplished reimbursement form
2. Original Official Receipt (w/ TIN) - Provisional Receipts are not accepted
3. Doctor's Prescription - Must bear the name of the employee/dependents patient
4. For Optical, Collection Receipt is accepted together with the certiificate
Sample Detailed Entries:
OR # OR Date Medicines Amount
1 1/08/2017 Zinnat 550.00
1 1/08/2017 Ventolin Syrup 200.00
1 1/08/2017 Hi-mox 250.00

Details of Medicine/s Purchased

OFFICIAL
RECEIPT # OFFICIAL RECEIPT DATE MEDICINE AMOUNT
IMMUNOPRO TAB 500 MG/10 MG
052282 08/07/2020 (Sodium Ascorbate) 950.40

1 1 1
TOTAL AMOUNT P 950.40
NOTES: 1
1. All documents to be submitted must be original and complete 4
2. Reimbursement claims must be filed within one month (30 days) from the date of purchase of medicines
3. Only prescribed outpatient medicines are reimbursable (over the counter medicines and vitamins are not allowed)
4. Since Provisional Receipts are not accepted, please ensure before purchasing that drugstore
will issue an Official Receipt (OR).
5. For follow through medication, a photocopy of applicable documents (Doctor's Prescription)
can be considered in lieu of original copy previously submitted.

____________________________ 12/01/2020
SIGNATURE OF CLAIMANT DATE SIGNED

Employee Services - Benefits Admin

CP # : 0918-9188573 Trune Line: 634-1111 local 1868 benad.company@jws.com.ph