Mezzanine, Grand Riviera Suites

Roxas Blvd. corner Padre Faura St., Ermita, Manila

Contact Nos.: 8247 1878 / 8521 9927 / 8293 2484 /
8371 4532 / 8365 5233 / 8371 4511 / 8365 8469 /
0977 804 2137 (Globe) / 0925 652 1927 (Sun)
carehealthplus@gmail.com
www.carehealthplus.com
Letter of Authorization (LOA)
CONSULTATION
To GENERAL MALVAR HOSPITAL Address of Provider
RTA RTA-2207070180 PAN AMCC910076-070722
LOA CF-1207051 Date LOA Issued: July 07, 2022 Valid Until July 21, 2022
Member’s Name DREW MARCO CRUZ Date of Birth March 03, 2007 Age 15
Company Name Gender Male
Health Card Number VPP-5000031955-0 Effectivity / Expiry Date May 04, 2022 to May 3, 2025
This is to confirm that the person whose name is indicated hereunder is a bonafide Member of CareHealth Plus Systems International, Inc.
Chief Complaint (Member‘s Complaint report of illness/injury)
FF UP CHECK UP

To be accomplished by the Attending Physician

History of Present Medical / Dental Illness or other Significant Medical / Dental History

Significant Physical Examination Findings (N/A if Dental)

Clinical Impression (N/A if Dental)

Laboratory Request / Dental Procedures

DREW MARCO CRUZ DR JOSE SOLLANO JR

Member’s Signature over Printed Name Physician’s Signature over Printed Name
Issued by Received by
Joyce Detona
(This is a computer generated document. No signature is required) Signature over Printed Name
Date and Time Issued July 07, 2022 / 5:48:pm Date and Time Received
REMINDER Please attach this Letter of Authorization (LOA) together with the other supporting documents to the Statement of Account (SOA)
and send to CareHealth Plus, Mezzanine, Grand Riviera Suites, Roxas Blvd. cor. Padre Faura St., Ermita, Manila. Thereafter, kindly advise
CareHealth Plus through call at (02) 8293 25 85 or e-mail at pa.carehealthplus@gmail.com.
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