CLR-FO-036

MediCard Philippines, Inc. Rev.00

22 FEB 2018
Head Office: 8th Floor, The World Centre Building,
330 Sen. Gil Puyat Ave, Makati City 1200
Tel. No.: 8884-9999 Fax No.: 8810-3855; 8848-6454
Website: www.medicardphils.com E-mail: inquiry@medicardphils.com

LABORATORY/DIAGNOSTIC EXAMINATION REQUEST FORM

Date: Nov 22, 2021 This form is valid from Nov 22, 2021 to Nov 24, 2021 only.
Name: VILLA, DHEXTER Age: 28 Sex: MALE
Company: TRENDS AND TECHNOLOGIES INC. (TRENDS) Medicard Account/I.D. Number: 32758369
Effectivity Date: Mar 01, 2016 Validity Date: Jun 30, 2022
Approval Code: MACEII1240971 Limit (including professional fee) COVERED
Request Physician: OLIVA, ANDREA MARIE M.
Diagnosis: HYPOCALCEMIA *****NOTHING FOLLOWS*****
Examination Requested: IONIZED CALCIUM *****NOTHING FOLLOWS*****
Examination to be done at: MAKATI MEDICAL CENTER

(Hospital/Clinic)
CONSENT:The patient or his/her authorized representative hereby consents (if patient cannot sign) to the processing and
disclosure of the patient’s information by MediCard, its representatives, and its accredited healthcare providers which is
necessary for the assessment of the patient’s coverage and the fulfillment of its obligations as health care provider, including
treatment of illnesses. Consent is also given to share utilization data (for corporate health program) with the Principal Member’s
Company for the proper administration of its health benefits program and medical results (for company endorsed patient) with
the patients endorsing company.
Withholding or withdrawal of such Consent shall relieve us from our obligation to deliver the appropriate services to the patient.
The undersigned declares that he has full authority to sign and further acknowledges that the patient is afforded with certain
rights and protection in accordance with Republic Act 10173 also known as the Data Privacy Act of 2012 and that he may visit
www.medicardphils.com/privacy or email privacy@medicardphils.com for more information.

MACE

Signature over printed name of patient MediCard Authorized Signatory

Signature over printed name

NOTE: For verification, kindly request company ID or any valid government ID.
Please submit original copy of this form together with your billing/statement of account to MediCard Claims Department.

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