Ceres 1. ] (a) Ful Namo of PATIENT Fst LEONAROT mplished by the attending physician, CERTIFICATE OF ATTENDING PHYSICIAN Middle Laat MENIIZA PRDTA CAD Hospitalization / Medical Reimbursement Claim (0) Are you related toe patont? Dives [ao Ives, whats the relatonanip? Z| Nature of compraint Accent LA sicaness 3] Whats your Diagnosis? (Please Print tit C Bang Ratere Hope ayy 4 7 [Wat ares contribuory causes? gS genet ee x Nature of — Lose Tratfe Accident = ‘Accidents caused by Machinery J hitby 2 Heawy Objet Person Fee, Exosion, Hot substance tacked ten by inset Animal Nitra Disaster Environmental Z Pricked by a Sharp Object TD Accidental Fait [Fi cutby substance / Device Llores [Paesreot eg PT 7] aia re ment |} esti yey 7] paar =a = Date and Time ce oes Pace of Accident House No.StreetSlig [subaivision'Brgy/Ortict [Town/City and Province 8] ,Outpationt treatment me Cvs oO™ Daea? ftesnsutaten | Roane Ctra Hosptal Name Mranita Portas Hoge Ak |amission Date Discharge Date (R-PBAO.CPMH Rev2 Feb 2011 PHILAM LIFE CUSTOMER CONFIDENTIAL0 amputtedhavelest| | vag in Was ary body part ‘Speci body par that war amputatedave let Re oso 7 Ty Date of Surge wwe way NT Type apse - Cpirioaoy Tur Gordy ray mm [od 7% Ta) When da the aymptanne a Sa] Wn ae oS | am] a the sciness beget? oesinte? 0° of | oar BIZ 5. aaron aS Taam wi poy ban aRoRE— POET ame ‘arose Taso Dales Deane o Condon 74] eth patent daabied? oN ce yea aa orator of dae” — [Fam we femlereas| yay | er] e oy TE] — Tse patent iagroned wit Cana? ove Bs 7 es oases he up RTAT an CeO TOaTTONE DOOW Tari of Deco Tasos Tresor ates Tipe aire 75| athe patents condtion a mental or nervous daorder? Cove Eakno 77-1 1s the treatment related o pregnancy, miscarriage, abortion or chibi? Cl ves Se 75-] tse conaion sustained from being intoxicated or under the influence of drugs? Cres ome | 78.1 isthe condition sustained from alcoholism or drug addiction?” Cire eRe 20-1 is tne treatment for routine physical check-up, rest cure, oF special nursing care? Cvs (no 7. fe patients condtion congenital? Loves No Z| ta the westmort for coumetc reasons, a devial Veatment oF an elecive surgery? Cvs No '23.| Is the treatment for circumcision, sterlization, artificial insemination, sex transformation, crveamenttinerty? Cle Te | 251s tne patients condition AIDS-related or due to a sexuialy transmied digease? Cle Dio ‘25.] (a) Doctors Full Name in print 1B) Doctors Signe ED R. GATCHALIAN, MD, (too Fe] paar Cine uRoLoey = owe NoLmeew ag itso Ate WPF esenontranDiot Kaun Fe Frownicty and Province maya 7 WA ea FF (0 PRC Line (0) Date bis form was rane 4 com My (0 (20224 ‘ORPBAO-CPNH . t Reve Feb 2011 PHILAM LIFE CUSTOMER CONFIDENTIAL