LEONCIO GENERAL HOSPITAL

Brgy. Pangobilian, Brooke’s Point, Palawan

5305

November 10, 2022

To whom it may concern,

I would like to apply for Healthcare Worker Compensation for my Covid-19 case last September
23, 2021. I am a Registered Medical Technologist, performing Covid 19 antigen swabbind and
testing. I have been admitted for six (6) days which started on September 23, 2021 to September
29, 2021 and quarantined for eight (8) days after the discharged at Leoncio General Hospital.

Attached herewith are the documents for your perusal.

Thank you for considering my application.

Prepared by:

MICHEL JOY A. CALMERIN, RMT

Medical Technologist
Laboratory Department

Noted by:

LOTUS FAY V. MANZANILLA,RN,MMHoA

Assistant Administrator
 LEONCIO GENERAL HOSPITAL
Brgy. Pangobilian, Brooke’s Point, Palawan
5305

Certificate of Involvement in Covid-19 Response

November 10, 2022

This is to certify that Mr/Ms. Sheryl M. Simyunn (Medical Social Worker) is involved in
COVID-19 response in line with the National Action Plan strategy Prevention, Detection,
Isolation, Treatment, Rehabilitation and Vaccination (PDITR+) such, Mr/Ms Sheryl M.
Simyunn has performed the following for the period of year 2021 up to present.

 Interviewing clients for medical assistance especially those family member who’s patient
tested positive of Covid 19
 Assisting patients/clients to comply their requirements for medical assistance

This certification is issued solely for the purpose of complying with the documents and
requirements as prescribed in the DOH-DBM Joint Circular No. 2022-0002. Implement
Guidelines on the Grant of Covid-19 Sickness and Death Compensation to Eligible Public and
Private Healthcare Workers (HCWs) and Non HCWs for FY 2022.

EVELYN G. PRESTO
HMO/Philhealth Officer
 DOH SICKNESS AND DEATH BENEFIT REQUIREMENTS

MILD/MODERATE

 Medical Certificate – with indicated signs, symptoms and diagnosis of Mild, Moderate, Severe of
Critical Covid 19. If not indicated, submit Certified true copy or original monitoring sheet
 Clinical Abstract or Discharge Summary – if admitted
 Quarantine Certificate – if facility quarantined
 + RTPCR or + Antigen Result – CTC
 Certificate of Covid 19 Response Involvement
 Original COE
 2 Govt valid ID’s – photocopy
 Application Letter
 CTC of Xray result signed by radiologist (severe/critical)

DOH SICKNESS AND DEATH BENEFIT REQUIREMENTS

MILD/MODERATE

 Medical Certificate – with indicated signs, symptoms and diagnosis of Mild, Moderate, Severe of
Critical Covid 19. If not indicated, submit Certified true copy or original monitoring sheet
 Clinical Abstract or Discharge Summary – if admitted
 Quarantine Certificate – if facility quarantined
 + RTPCR or + Antigen Result – CTC
 Certificate of Covid 19 Response Involvement
 Original COE
 2 Govt valid ID’s – photocopy
 Application Letter
  CTC of Xray result signed by radiologist (severe/critical)
DOH SICKNESS AND DEATH BENEFIT REQUIREMENTS

MILD/MODERATE

 Medical Certificate – with indicated signs, symptoms and diagnosis of Mild, Moderate, Severe of
Critical Covid 19. If not indicated, submit Certified true copy or original monitoring sheet
 Clinical Abstract or Discharge Summary – if admitted
 Quarantine Certificate – if facility quarantined
 + RTPCR or + Antigen Result – CTC
 Certificate of Covid 19 Response Involvement
 Original COE
 2 Govt valid ID’s – photocopy
 Application Letter
 CTC of Xray result signed by radiologist (severe/critical)