Letter of Authorization (LOA)

(OUT – PATIENT)

This is to certify that as of this date, below – mentioned Patient is a bonafide Member of CareHealth Plus Systems
International, Inc. He/she is entitled to the limit below under his/her plan and all necessary diagnostic and treatment,
subject to the condition/ limitations specified herein.

Hospital : GENTRI MEDICAL CENTER

DIAGNOSTIC/ procedure
APPROVAL FORM
Requested by:

Date: 1/3/2021 Priority Authorization Number:

Valid up to: 1/12/2021 HDOA100177026-01032021

Member’s Name AIRA JANE J. BOBADILLA Birthdate Age

ID Card No: GVN010000058734P Issue Date 7/27/2021

COMPANY: CAFÉ AMADEO

Chief Complaint: Past Medical History:

Diagnosis: ANNUAL PHYSICAL EXAM

Diagnostic Test/s or Procedures: Cardholder’s Signature:

✓ MEDICAL HX/EXAM
✓ CXR PA
✓ CBC
✓ U/A
✓ F/A
✓ FBS
✓ BUA
✓ ECG (30 y/o and above)
-------------------------------------------------------NOTHING FOLLOWS--------------------------------------------------------

Kindly send all Statement of Accounts and all Supporting Documents to CareHealth Plus Medical Payable Department together with
this LOA.

Prepared by: Checked by: Date&Time Prepared: __________

DULCE AMOR GREGORIO KATHERINE BENGAN, RN MSN MeHMgt Received by: ___________
Date&Time Received: __________

REMINDER: Please send the white copy CareHealth Plus Systems International Inc., Suite 905 L & S Building 1414 Roxas Blvd., Ermita
Manila. Please notify Medical Payable Department at (02) 5219927 or email us at carehealthplus@gmail.com if you do not receive
your payment within thirty (30) days from our receipt of your bills.

White: Carehealth Plus Yellow: Hospital Copy Green: Branch Copy