Form No.

_________________

Philippine Association of Medical Technologists, Inc.

The Only PRC Accredited Professional Organization for Medical Technologists
Unit 1720 Cityland 10 Tower 2, 6817 Ayala Avenue, Makati, 1000 Metro Manila

BENEFIT CLAIM FORM FOR COVID-19

Membership Details
Surname Given Name Middle Name

Permanent Address Contact No.

Email Address

Work Address Entity

□ Government
□ Private
□ Others ______________________
Section Assigned (if applicable)

PAMET ID No. Membership Validity Until PAMET Chapter

_____________ /_________
Month Year
If claimant is deceased, full name of beneficiary:

Case Details
Date of Confirmation of Disease Severity Disease Outcome
Disease Status □ Moderate □ Ongoing Confinement
□ Severe □ Recovered
_____ / _____ /_________ □ Critical _____ / _____ /_________
Date Month Year Date Month Year
□ Deceased
_____ / _____ /_________
Date Month Year
Probable Mode of Case Comments (use additional sheets if necessary):
Transmission ____________________________________________________________________
□ Community-Acquired ____________________________________________________________________
____________________________________________________________________
□ Laboratory-Acquired ____________________________________________________________________
□ PPE Failure ____________________________________________________________________
Others _______________________ ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________

Note: Accomplish this form and attach medical certificate or medical abstract stating disease severity and dates of
hospital confinement as well as updated PAMET ID or proof of membership payment. Send this form and attachments
by email to pametcovid19hotline@gmail.com.
Declaration
I affirm under oath on the veracity of the _________________________________________________
information provided in this form. I also authorize Signature over Printed Name
PAMET and its representatives access to my
_____ / _____ /_________
information to validate my claims. Date Month Year

Data Privacy Consent

I have read this form, understood its contents and consent to the processing of my personal
data. I understand that my consent does not preclude the existence of other criteria for lawful
processing of personal data, and does not waive any of my rights under the Data Privacy Act of
2012 and other applicable laws.

Full Name Date

_____ / _____ /_________
Signature Date Month Year

Case Investigated by: Comments (use additional sheets if necessary):

______________________________
Signature Over Printed Name
_____ / _____ /_________
Date Month Year
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________

Case Endorsed by: Comments (use additional sheets if necessary):

______________________________
Signature Over Printed Name
_____ / _____ /_________
Date Month Year
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________

Case Reviewed by: Comments (use additional sheets if necessary):

______________________________
Signature Over Printed Name
_____ / _____ /_________
Date Month Year
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________

Claim Approved? □ YES □ NO

Claim Notification by:
______________________________
Signature Over Printed Name
_____ / _____ /_________
Date Month Year
Comments (use additional sheets if necessary):
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________