REPUBLIC OF THE PHILIPPINES }

PROVINCE OF SOUTH COTABATO }

CITY OF KORONADAL } S.S.

AFFIDAVIT OF COMPLIANCE AND EXPLANATION

I, MISAEL T. BAYUGA, a Filipino, of legal age, with office address at Juanaria

Marcial Memorial Hospital, Brgy. Yanco, Banga, South Cotabato, do hereby state
under oath that:

1. I am the Medical Director of Juana Marcial Memorial Hospital and am the duly
authorized representative of Juana Marcial Memorial Hospital;
2. Juanaria Marcial Memorial Hospital is a Philhealth Accredited health care
institution assigned with Accreditation No.________________ granted on
_______________. The HCI is located at Brgy. Yangco, Banga, South
Cotabato, and has a _____ bed capacity;
3. I have received the ORDER TO PRODUCE DOCUMENTS/ORDER TO
JUSTIFY/EXPLAIN from Philippine Health Insurance Corporation Regional
Office XII dated April 12, 2021 regarding the possible violation of Sec. 160 of
the RIRR of RA 7875 as amended, by our institution in relation to its
reimbursement claims for the Treatment of Lorenzo Ortaliza Directo on
December 13-15,2015;
4. The order shows that there is an overlapping confinement/treatment of
Lorenzo Ortaliza Directo with Lariosa Hospital for the same Confinement date;
5. Juanaria Marcial Memorial Hospital did not participate in nor performed any
acts that are indented to defraud PHIC:
6. This affidavit is in compliance to the abovementioned order and that the
documents ordered produced are attached to this affidavit:
a. A copy of the Claim Form 2 for the December 13-15 2014 confinement
of Lorenzo Ortaliza Directo is attached and marked as ANNEX 1;
b. A copy of the page of Admission Logbook covering the dates
December 13-14, 2014 is attached and marked as ANNEX 2;
c. A copy of the pages of the Admission Logbook covering the dates
December 12-15, 2015 is attached and marked as ANNEX 3;
d. A copy of the Clinical Chart is attached and marked as ANNEX 4;
e. A copy of the Consent Slip for Admission of Lorenzo Ortaliza Directo
for his December 13-15, 2014 confinement is attached and marked as
ANNEX 5;
f. A copy of the patient’s Statement of Accounts for his confinement from
December 13-15, 2014 is attached and marked as ANNEX 6;
g. A copy of the patient’s Claim Form 3 for his confinement from
December 13-15 2014 is attached and marked as ANNEX 7
7. This affidavit is also an explanation as to why we believe that PHIC is
mistaken in its allegation that there was double confinement;
8. The records of Juanaria Marcial Memorial Hospital indicate that Lorenzo
Ortaliza Directo was confined for treatment from December 13-15, 2014”
a. The page of the admission logbook attached as ANNEX 2 shows that
Lorenzo Ortaliza Directo was admitted on December 13 2014 at 10:35
AM and discharged on December 15, 2014 at 2:05 PM. The entry on
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 the abovementioned page indicating this is highlighted and marked as
ANNEX 2-1.
b. The copy of the Clinical Chart of Lorenzo Ortaliza Directo attached as
ANNEX 4 have dates indicative of his confinement period and clearly
shows his confinement period is between December 13-15, 2014;
i. The Comprehensive Medical History Form in the clinical chart is
dated at December 13, 2014, this is highlighted and marked as
ANNEX 4-1;
ii. The Doctors Order Sheet in the clinical chart has 3 dates,
December 13, 2014, December 14, 2014, and December 15,
2014, highlighted and marked as ANNEX 4-2, ANNEX 4-3, and
ANNEX 4-4, respectively.
iii. The laboratory results in the clinical chart for fecalysis, urinalysis
and hematology all have December 13, 2014 as dates. The
dates on the fecalysis, urinalysis and hematology results are
highlighted and marked as ANNEX 4-5, ANNEX 4-6, and
ANNEX 4-7, Respectively;
iv. The Temperature and Pulse Rate Page of the clinical chart has
3 dates indicating the monitoring of his temperature and pulse
rate during the course of his confinement. The dates on the
page are for December 13, December 14, and December 15,
2014. These dates are highlighted and marked as ANNEX 4-8,
ANNEX 4-9, and ANNEX 4-10, respectively;
v. The Medication Sheet in the chart has 5 dates indicated:
1. The first date indicated is the Date Admitted portion of the
document which indicated “12-13-14”, this is highlighted
and marked as ANNEX 4-11;
2. The date ordered column of the page has a date which
states 12/13/14, this is highlighted and marked as
ANNEX 4-12;
3. The Date Signature portion of the page has its first 3
columns that has 13, 14, 15 as its entries on its first 3
columns, these are highlighted and marked as ANNEX 4-
13, ANNEX 4-14, and ANNEX 4-15, respectively;
vi. The Intravenous Fluid Flow Sheet of the Chart has 13 dates
indicated:
1. The Date Admitted portion of the document has “12-13-
14” written on it, this is highlighted and marked as
ANNEX 4-16;
2. The Date and Time hooked column has 6 dates indicating
12-13-14 twice, 12-14-14 three times, and 12-15-14,
once. The entire column is highlighted and marked as
ANNEX 4-17
3. The date and time consumed column has 6 dates
indicating 12-13-14 once, 12-14-14 thrice, and 12-15-14
twice. The entire column is highlighted and marked as
ANNEX4-18;
vii. The Nurses Notes part of the chart has 3 dates indicated:

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 1. On the obverse side of the page, the date column has 12-
13-14 written as an entry. This is highlighted and marked
as ANNEX 4-19;
2. On the reverse side of the page there are 2 dates written
in the date column of the page, 12-14-15 and 12-15-15.
These dates are highlighted and marked as ANNEX 4-21.
3. The Discharge Summary portion of the Chart has 2
dates; The Date Admitted portion has 12-13-14 as an
entry and the Date of Discharge has 12-15-14 as an
entry. These dates are highlighted and marked as
ANNEX 4-22 and ANNEX 4-23 respectively.
c. The Consent Slip for Admission of Lorenzo Ortaliza Directo attached
as ANNEX 5 shows it was signed by his wife, Virginia C. Directo on
December 13, 2014. The Date portion of the document is highlighted
and marked as ANNEX 5-1;
d. The statement of account attached as ANNEX 6 shows 3 dates:
i. The date portion of the document shows December 15, 2014 as
an entry. This is highlighted and marked as ANNEX 6-1;
ii. The Date of Admission portion of the document shows
December 13, 2014 as the entry. This is highlighted and marked
as ANNEX 6-2;
iii. The Date of Discharge portion of the document shows
December 15, 2014 as the entry. This is highlighted and marked
as ANNEX 6-3;
e. The Claim Form 2 Attached as ANNEX 1 shows 3 dates:
i. On the obverse side of the document:
1. The Date of Admission portion of the document shows
12-13-2014 as the entry. This is highlighted and marked
as ANNEX 1-1;
2. The Date of Discharge portion of the document shows
12-15-2014 as the entry. This is highlighted and marked
as ANNEX 1-2;
ii. On the reverse side
1. The certification part of the document has the name and
signature of the Attending Physician and the date in
which it was signed. The date portion indicated 12-15-
2014. This is highlighted and marked as ANNEX 1-3;
f. The Claim Form 3 Attached as ANNEX 7 shows 3 dates:
i. On the obverse side of the document:
1. The Date of Admission portion of the document shows
12-13-2014 as the entry. This is highlighted and marked
as ANNEX 7-1;
2. The Date of Discharge portion of the document shows
12-15-2014 as the entry. This is highlighted and marked
as ANNEX 7-2;
g. The pages of the admission logbook attached as ANNEX 3 shows no
entry of any admission or discharge of Lorenzo Ortaliza Directo;
9. The hospital tried to get sworn affidavits of the admitting officer and the
Attending Physician as attachments to this affidavit, however they are no

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 longer connected with Juanaria Marcial Memorial Hospital, the admitting
officer since__________ and the Attending Physician since___________;
10. The attached documents will prove that there was no Overlapping of claims
since the claim of Lariosa Hospital was Lorenzo Ortaliza Directo’s
confinement for Vertiginous Disorders from December 13-15, 2015, while the
claims made by our hospital were for Peptic Ulcer Disease without
Hemorrhage from December 13-15, 2014;
11. The reimbursement claim was made with no intention to defraud PHIC. The
claim was made in compliance with all the procedural requirements and was
to our understanding covered by the PHIC.
12. The foregoing affidavit and attached documents is further proof that Juanaria
Marcial Memorial Hospital provided Lorenzo Ortaliza Directo the benefits due
him under the National Health Insurance Program during his confinement
from December 13-15, 2014;

WHEREFOR, premises considered, it is respectfully prayed that the

aforementioned explanation be considered and such other reliefs the corporation
deems just and equitable, subject to government rules and regulations.

IN WITNESS HEREOF, I have hereunto affixed my signature this ______ day of

May 2021 in the City of Koronadal, Philippines.

MISAEL T. BAYUGA
Affiant

SUBSCRIBED AND SWORN to before me this _____________ at City of

Koronadal, South Cotabato, Philippines.

Doc No. :____

Page No:____
Book No:____
Series of_____;

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List of Annexes

1. ANNEX 1 – Claim Form 2

a. ANNEX 1-1 Obverse Side Date of Admission Entry highlighted
b. ANNEX 1-2 Obverse Side Date of Discharge Entry highlighted
2. ANNEX 2 – Page of Admission Logbook from Dec. 13-15, 2014
a. ANNEX 2-1 Highlighted Admission and Discharge entry
3. ANNEX 3 – Pages of Admission Logbook from Dec. 13-15, 2015
4. ANNEX 4 – Patient Chart
a. ANNEX 4-1 Comprehensive medical history form date highlighted
b. ANNEX 4-2 Doctor’s orders sheet date 12-13-14 highlighted
c. ANNEX 4-3 Doctor’s orders sheet date 12-14-14 highlighted
d. ANNEX 4-4 Doctor’s orders sheet date 12-15-14 highlighted
e. ANNEX 4-5 Fecalysis result date 12-13-14 highlighted
f. ANNEX 4-6 Urinalysis result date 12-13-14 highlighted
g. ANNEX 4-7 Hematology result date 12-13-14 highlighted
h. ANNEX 4-8 Temperature and Pulse Rate sheet date column 12-13-14
highlighted
i. ANNEX 4-9 Temperature and Pulse Rate sheet date column 12-14-14
highlighted
j. ANNEX 4-10 Temperature and Pulse Rate sheet date column 12-15-14
highlighted
k. ANNEX 4-11 medication sheet admission date 12-12-14 highlighted
l. ANNEX 4-12 medication sheet date ordered column entry 12-13-14
m. ANNEX 4-13 medication sheet date signature column entry “13” highlighted
n. ANNEX 4-14 medication sheet date signature column entry “14” highlighted
o. ANNEX 4-15 medication sheet date signature column entry “15” highlighted
p. ANNEX 4-16 Intravenous Fluid Flow sheet date admitted entry 12-13-14
highlighted
q. ANNEX 4-17 Intravenous Fluid Flow Date & Time Hooked Column and
Entries highlighted
r. ANNEX 4-18 Intravenous Fluid Flow Date & Time consumed Column and
Entries highlighted
s. ANNEX 4-19 Nurses Notes Obverse Page date Colum Entry 12-13-14
highlighted
t. ANNEX 4-20 Nurses Notes Reverse Page date Colum Entry 12-14-14
highlighted
u. ANNEX 4-21 Nurses Notes Reverse Page date Colum Entry 12-15-14
highlighted
v. ANNEX 4-22 Discharge Summary Date Admitted Entry 12-13-14 highlighted
w. ANNEX 4-23 Discharge Summary Date of Discharge Entry 12-15-14
highlighted
5. ANNEX 5 – Consent Slip for Admission
a. ANNEX 5-1 Date of Consent Form Highlighted
6. ANNEX 6 – Statement of Accounts
a. ANNEX 6-1 Date of Document highlighted
b. ANNEX 6-2 Date of Admission Entry “December 13, 2014” highlighted
c. ANNEX 6-3 Date of Discharge Entry “December 15, 2014” highlighted
7. ANNEX 7 – Claim Form 3
a. ANNEX 7-1 Obverse Side Date of Admission Entry highlighted
b. ANNEX 7-2 Obverse Side Date of Discharge Entry highlighted
c. ANNEX 7-3 Reverse Side Date of Certification Entry Highlighted