HOSPITALIZATION CLAIM FOR PAYMENT

EMPLOYEES COMPENSATION
PART I - HOSPITAL TO FILL IN ALL ITEMS
Hospital Address PMC No.

Paient/Employee Date Admitted Date Discharged Date of Dest.

Diagnoses Hospital Charges (Ward Services) EC Actual

A. Rm. Bd. & Special Charges
(Attached Statement of Actual Charge)
Final Diagnoses
B. Surgical

C. Medicines
GSIS No. Sex Age
( )M ( )F TOTALS
Address of Employees

CERTIFICATION
Employer I certify that the services claimed are duly recorded in the patient's charts, and the
information given in this form including the attached copy of the patient's statement of
actual charges is correct
Address of Employer

For GSIS Use (signature Verified by) Printed Name of Hospital Authorized Representative

Remarks Official Capacity

Signature of Authorized Representative Date Signed

PART II - DOCTOR TO FILL IN ALL ITEMS

Do not
Brief Offiial History of the Case(For clarification, use reverse side hereof) Fill

Code No

CHARGES
For services rendered, always state the
nature of service, surgical operation EC Actual
performed, if any, and date of each.
A. Name of Attending Physician/Surgeon Address

Signature Date Signed P P

PMA No. TAN No.

Services Rendered

B. Name of Attending Physician/Surgeon Address

Signature Date Signed P P

PMA No. TAN No.

Services Rendered/Operation Performed

C. Name of Anesthesiologist Address

Signature Date Signed P P

PMA No. TAN No.

Services Rendered

MEDICAL EVALUATION REPORT ( For GSIS use only)

Nature of Degree of Injury/Sickness
Noted:_____________________
Signature:__________________
Designation:________________
Date: ______________________

NOTICE: Any one who falsifies essential information requested by this or a related form may, upon conviction be subject to fine and
imprisonment under the law. All data required on this form are necessary for adjudication of the claim. The GSIS will not
adjudicate any claim where forms are not properly or completely accomplished.