TO: Philippine Health Insurance Corporation

Philhealth Regional Office

Cagayan de Oro City

RE: DIRECT FILE DIALYSIS CLAIM

Dear Sir/Ma’am,

Greetings!

I am Gina U. Raupan, 53 years old, the wife of MAMARINTA C. RAUPAN. Residing at Prk.
Malinawun, Pandan, Sta. Filomena, Iligan CIty. MAMARINTA C. RAUPAN is a dialysis
patient at Mercy Community Hospital, Inc.

I am sending the following documents to support my request for reimbursement of the

PHIC share we have directly paid to the hospital.

Dialysis Procedure Date OR DATE OR # AMOUNT PAID

11/28/2020 11/28/2020 176021 Php2,400.00

12/01/2020 12/01/2020 176232 Php2,400.00

TOTAL Php4,800.00

Attached are completely filed-up and signed forms and documents:

1. CSF
2. CF-2
3. MCH Statement of Account
4. MCH Official Receipt
5. Waiver Form for Directly Filled Claims
6. Hemodialysis Unit Monitoring Sheet
7. MDR
8. Valid IDs for the patient and the representative (wife)

Looking forward for favorable action to this request.

Thank you and best regards.

Respectfully Yours,

GINA U. RAUPAN

Contract # 0977-7306958
 March 23,2021

Dear Sir/Ma’am,

I am Mamarinta C. Raupan writing to authorize Gina

U. Raupan, my wife to transact/claim my
reimbursement regarding Dialysis Direct Claim in my
absence.

This letter will be valid until I provide notice

otherwise. Please find the name and signature of the
person below to identify the person on her arrival.

I really appreciate your support and feel grateful for

your cooperation.

Thank you and God bless!

Respectfully yours,

MAMARINTA C. RAUPAN

GINA A. RAUPAN