4F Civic Prime Building Unit 405-410, Civic Drive 4F Civic Prime Building Unit 405-410, Civic Drive

Filinvest, Alabang, Muntinlupa City 1781 Filinvest, Alabang, Muntinlupa City 1781
0917-8055424 & 0917-8855424 (calls only) 0917-8055424 & 0917-8855424 (calls only)
0917-8255424 & 0917-8955424 (call and text) 0917-8255424 & 0917-8955424 (call and text)
Tel. No.: (632) 8844-5773 / Fax No.: (02) 8886-4478 Tel. No.: (632) 8844-5773 / Fax No.: (02) 8886-4478

OUTPATIENT LETTER OF AUTHORITY OUTPATIENT LETTER OF AUTHORITY

CONSULTATION
1. Copy of this LOA should be faxed by the doctor to (02) 8886-4478 or sent to CREDIT &
COLLECTION of the hospital to be submitted within 30 days to Lacson & Lacson Insurance Brokers,
Inc. for payment of consultation fee.
2. If laboratory / diagnostic tests are required, doctor should return a copy to patient.
Date/Time : July 22, 2020 / 03:35:48 pm (valid for 5 days from date of issuance)
Doc No. : VECO-2020-x-00686
OUTPATIENT PROCEDURE
1. Patient should present this copy to Credit and Collection for validation.
2. Patient must present validated laboratory form to the laboratory section of the accredited hospital
for prescribed procedures to be done.
3. Credit and Collection should forward all billings with copy of this laboratory form within 30 days to
Lacson & Lacson for collection of payment.
Date/Time : July 22, 2020 / 03:35:48 pm (valid for 5 days from date of issuance)

Consultation Date : Doc No. : VECO-2020-x-00686

Consultation Date :
To : Dr. Lim, John Alfred
University of Cebu Medical Center, Inc. To : Dr. Lim, John Alfred
University of Cebu Medical Center, Inc.
Re : YBANEZ, DANIEL LLOYD M
VISAYAN ELECTRIC CO., INC. Re : YBANEZ, DANIEL LLOYD M

(PATIENT) YBANEZ, DANIEL LLOYD M VISAYAN ELECTRIC CO., INC.

--------------------------------------------------------------------------- (PATIENT) YBANEZ, DANIEL LLOYD M

Complaint : ---------------------------------------------------------------------------

Diagnosis : Complaint :
Diagnosis :

Prescribed laboratory & Diagnostics test(s)

Prescribed laboratory & Diagnostics test(s)

Please honor this electronically generated LOA.

Please honor this electronically generated LOA.

Professional Fee : Lim, John Alfred Professional Fee : Lim, John Alfred
Print Doctor's Name/Signature Print Doctor's Name/Signature

Lilibeth Y. Lacson, EVP Tin : Lilibeth Y. Lacson, EVP Tin :

This Letter of Authority (LOA) provides you access to Lacson & Lacson's network of accredited health care providers
included in your insurance benefit with your employer. To serve you better, the information you will provide us such
as your name, employment, age, medical results and documents will be used by our representatives/employees to
process your insurance claim. In the process of helping you out with your claim, we will receive your statement of
accounts, medical records, and other documents related to your use of our LOA. This information may be accessed
by your employer for the purpose of reviewing your benefits or in conducting survey studies.
Should you have any concerns about the privacy of your information, please contact us at concerns@llibi.com or
communicate it immediately with any of our client care representatives.
This Letter of Authority (LOA) provides you access to Lacson & Lacson's network of accredited health care providers
included in your insurance benefit with your employer. To serve you better, the information you will provide us such
as your name, employment, age, medical results and documents will be used by our representatives/employees to
process your insurance claim. In the process of helping you out with your claim, we will receive your statement of
accounts, medical records, and other documents related to your use of our LOA. This information may be accessed
by your employer for the purpose of reviewing your benefits or in conducting survey studies.
Should you have any concerns about the privacy of your information, please contact us at concerns@llibi.com or
communicate it immediately with any of our client care representatives.