Certificate of ‘classification of at-risk individuals and actual charges for SARS-CoV-2 test e {088 8. Menem GENERAL HOSEN ® Date To PhitHeatth: This is to certify that based on our records, ‘who belongs to sub-group. Patients lastname, frst name, name extension, middle name based on DOH DM No. 2020-0258-A, was tested for SARS-CoV-2 at JOSE B, LINGAD MEMORIAL GENERAL HOSPITAL ‘Name of Philfealth accredited SARS.CoV-2 testing laborstory/HCP Date/s of specimen and incurred the following charges: alection (wend Saheveeh Place a (v) in the appropriate tick box 1 Nocharge to patient 1 ttwith actual charges, indicate the following: i I [Total actual charges item ‘Amount (Php) ‘Amount after application of discounts/deductions (senior t = citizen, persons with disability, guarantee letter, etc.) | MONSERRAT S. CHICHIOCO, MD, CHA, MBA-H, FPSP, FECHA ‘Signature over printed name of the authorized testing laboratory/HCP representative MEDICAL CENTER CHIEF IL Designation of the authorized testing laboratory/HCP representative Date signed Conforme: ‘Signature over printed name of the member/patient/ authorized representative Date signed [Relationship of the representative | [J Spouse chile Cl Others, | to member/patient 1D Siblings Parent specify | Reason for signing on behalf of |_ member/patient | the | Cy Patients incapacitated L__© other reasons: