JOLLIBEE FOODS CORPORATION

Optical and Outpatient Medicine Reimbursement Form

PRINT AND SEND CLEAR

2/6/2021
(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
Sample Detailed
Detailed Entries:
Entries:
OR
OR #
# OR
OR Date
Date Medicines
Medicines Amount
Amount
1
1 1/08/2017
1/08/2017 Zinnat
Zinnat 550.00
550.00
1
1 1/08/2017
1/08/2017 Ventolin
Ventolin Syrup
Syrup 200.00
200.00
1
1 1/08/2017
1/08/2017 Hi-mox
Hi-mox 250.00
250.00
2
2 1/08/2017
1/08/2017 Ponstan
Ponstan 250mg
250mg 100.00
100.00

Details of Medicine/s Purchased

OFFICIAL
RECEIPT # OFFICIAL RECEIPT DATE MEDICINE AMOUNT
IMMUNOPRO TAB 500 MG/10 MG
052282 8/7/2020 (Sodium Ascorbate) 760.00
0291 8/11/2020 Eyeglasses 6,500.00

2 2 2
TOTAL AMOUNT P 7,260.00
NOTES: 2
1. All documents to be submitted must be original and complete 8
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.

____________________________ 2/6/2021
    SIGNATURE OF CLAIMANT                                                 DATE SIGNED
Employee Services - Benefits Admin
CP # : 0918-9188573 Trune Line: 634-1111 local 1868 benad.company@jws.com.ph
Employee Services - Benefits Admin
SBU Contact Person
JOLLIBEE WORLDWIDE SERVICES ES-Benefits Admin
JOLLIBEE WORLDWIDE SERVICES LOGISTICS ES-Benefits Admin
JOLLIBEE FOODS CORPORATION ES-Benefits Admin
ZENITH FOODS CORPORATION ES-Benefits Admin
FRESH N' FAMOUS FOODS, INC. - CHOWKING ES-Benefits Admin
FRESH N' FAMOUS FOODS, INC. - GREENWICH ES-Benefits Admin
RED RIBBON BAKESHOP, INC. ES-Benefits Admin
MANG INASAL PHILIPPINES INC. ES-Benefits Admin
FREEMONT FOODS CORPORATION ES-Benefits Admin
 Contact No. Email Address
CP # : 0918-9082585 Trunk Line: 634-1111 local 1867 benad.company@jws.com.ph
CP # : 0918-9082585 Trunk Line: 634-1111 local 1867 benad.company@jws.com.ph
CP # : 0918-9188573 Trune Line: 634-1111 local 1868 benad.company@jws.com.ph
CP # : 0918-9082585 Trunk Line: 634-1111 local 1867 benad.company@jws.com.ph
CP # : 0918-9082585 Trunk Line: 634-1111 local 1867 benad.company@jws.com.ph
CP # : 0998-8697483 Trunk Line: 634-1111 local 1693 benad.company@jws.com.ph
CP # : 0998-8697483 Trunk Line: 634-1111 local 1693 benad.company@jws.com.ph
CP # : 0998-8697483 Trunk Line: 634-1111 local 1693 benad.company@jws.com.ph
CP # : 0918-9082585 Trunk Line: 634-1111 local 1867 benad.company@jws.com.ph