Claim No.

______________

DEPARTMENT OF NATIONAL DEFENSE

PHILIPPINE VETERANS AFFAIRS OFFICE
VETERANS MEMORIAL MEDICAL CENTER

VETERANS HOSPITALIZATION PROGRAM

REQUEST FOR REIMBURSEMENT FORM

Date: ________________

THE DIRECTOR
Veterans Memorial Medical Center

North Ave., Diliman, Quezon City

Madam:

Request reimbursement of my expenses incurred during my hospitalization/treatment in PVAO-VMMC accredited hospital

and other benefits under the Veterans Hospitalization Program in the amount of:

______________________________________________________________________________________ (P_______________)
(Amount in Words) (Amount in Figures)
Attached are the documentary requirements for my reimbursement. I understand and will abide by the rules and regulations
set forth in the prioritization and budget scheme of the program.

Thank you.

Respectfully yours,

________________________________
Signature of Patient
Name of Patient: Veteran Status:
____ RPV-WW II (WW II Veteran) ____ RPV-AFP (AFP Veteran)
____ RPVD-WWII (WWII Dependent) ____ RPVD-AFP (AFP Dependent)
Mailing Address/Telephone No.:

DOCUMENTARY REQUIREMENTS NATURE OF REIMBURSEMENT

__ Official Receipt/s
__ Certificate of Confinement/Treatment ___ Angioplasty
__ Proof of Veteran Status (e.g. PVAO ID;VMMC ID; PVAO Certificate) ___ Cataract Surgery :___(L) ___(R) ___(Both)
__ Statement of Account issued by the Hospital (for Hospital Subsidy) ___ Chemotherapeutic Agent
__ Certificate of Waiting List from RDU-VMMC (for Hemodialysis) ___ Coronary Angiogram
__ Audiometry Result (for Hearing Aid) ___ Dentures : ___ Upper ___ Lower ___(Both)
__ Medical Abstract (for Chemotherapeutic Agent; Orthopedic Implant) ___ Endoaneurysmectomy for Thoracic/Abdominal Aortic Aneurysm
__ Result (for Coronary Angiogram; Angioplasty; Pacemaker Placement) ___ Hearing Aid: ___(L) ___(R) ___(Both)
Additional Requirements (if the patient is deceased): ___ Hemodialysis Dialysis
__ Photocopy of Death Certificate ___ Hernia Mesh
__ Photocopy of Marriage Contract (claimant shall be the spouse) ___ Hospital Subsidy
__ Identification of the Claimant ___ Orthopedic Braces
(Claimant shall be the son/daughter if both patient & spouse are deceased) ___ Orthopedic Implant
__Photocopy of Death Certificate of the patient and the spouse ___ Pacemaker Placement ____(Temp) ____(Permanent)
__ Birth Certificate
__ Notarized Waiver of Siblings/Deed of Assignment
__ Identification of the Claimant

Evaluated as to Completeness of Documentary Requirements: Recommend Approval:

FELIZA P. BLANDO HELEN G. COCSON

Asst. Chief, Medical Administrative Section Chief, Medical Administrative Section
Approved By:

DOMINADOR M. CHIONG, JR., M.D.

Chairman, VHP Committee

Revised July 2015