Department of Health

NATIONAL REFERENCE LABORATORY

Lung Center of the Philippines
Department of Pathology and Laboratory
Quezon Avenue Ext., Quezon City Website: lcp.gov.ph
Telephone: 89246101 loc. 4041-4043 Email: lcpnrlcc2020@gmail.com

GENERAL INFORMATION SHEET

(Answerable Online thru Google Form)

2021 NATIONAL EXTERNAL QUALITY ASSESSMENT SCHEME in CLINICAL CHEMISTRY

Documents REQUIRED for Submission to LCP-NRL in hard copy:
(thru individual courier; walk-in applicants are not accepted)
● General Information Sheet
● Order of Payment Form
● Photocopy of the 2021 Laboratory LICENSE TO OPERATE
● Original machine validated bank deposit slip

NEQAS-CC Participation: Old Participant. Year of Last Participation: 2020

Name of Clinical Laboratory: (based on your latest License to Operate) Classification by Ownership:

MEDICUS DIAGNOSTICS AND MEDICAL CLINICS-SARA Private Secondary Free-Standing

BRANCH

Complete Address: C. Castor & Improggo Sts. Poblacion Market, Sara Iloilo

Contact Details: Laboratory Email Address: medicuslab.sara@gmail.com

Mobile Number: 09171356611
Telephone Number: 392-0015

Head of Laboratory: Name: ANNA VICTORIA J. SOMBONG

Contact Number: 09176213088

Laboratory Staff only: (to receive the NRL Documents and NEQAS-CC Samples)

Name of Laboratory Staff Designation Mobile Number

LALAINE JOY GARCIA LABORATORY SECTION CHIEF 09611546458

ELIM CARMEL ARAÑO MEDICAL TECHNOLOGIST 09283400737

CLARISSA JOY DORDE MEDICAL TECHNOLOGIST 09565285739

For LCP-NRL Staff only:

Over the Counter O.R. No: ______________ NRL-CC CONTROL NO.

Cash O.R. Date: _____________ 2021 - _______________

Mode of
Payment: Check Amount: P 8,000.00 Date Received:

Bank Transaction
Date of deposit: _________________________
*Send this Form to LCP-NRL thru courier
 Department of Health
NATIONAL REFERENCE LABORATORY
Lung Center of the Philippines
Department of Pathology and Laboratory
Quezon Avenue Ext., Quezon City Website: lcp.gov.ph
Telephone: 89246101 loc. 4041-4043 Email: lcpnrlcc2020@gmail.com

ORDER OF PAYMENT FORM

(Answerable Online thru Google Form)

2021 NATIONAL EXTERNAL QUALITY ASSESSMENT SCHEME in CLINICAL CHEMISTRY

LCP NRL FILE COPY

REMINDERS:
1. During this time of Covid-19 Pandemic, we strongly advise to transact payment through the Land Bank Account.
2. Your respective Official Receipt will be delivered to your Laboratory together with the NEQAS-CC samples and other NRL documents.
3. Advanced payment for the next NEQAS Cycle is NOT ACCEPTABLE.

Name of Clinical Laboratory: MEDICUS DIAGNOSTICS AND MEDICAL CLINICS-SARA BRANCH

Mode of Payment: For Check payments only:

Cash Bank Transaction Bank: RIZAL COMMERCIAL BANKING
CORPORATION
Check Over the Counter Branch: LEDESMA AND QUEZON STS. ILOILO
CITY
Check No.: 1200009747
Date Issued: 4/28/2021
::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::

FOR LCP NRL STAFF ONLY:

O.R. No.: __________________ O.R. Date: ________________ Amount: P 8,000.00

Received by: _______________ Date Received: :____________

Department of Health
NATIONAL REFERENCE LABORATORY
Lung Center of the Philippines
Department of Pathology and Laboratory
Quezon Avenue Ext., Quezon City Website: lcp.gov.ph
Telephone: 89246101 loc. 4041-4043 Email: lcpnrlcc2020@gmail.com

ORDER OF PAYMENT FORM

(Answerable Online thru Google Form)

2021 NATIONAL EXTERNAL QUALITY ASSESSMENT SCHEME in CLINICAL CHEMISTRY

LCP - CASHIER DIVISION

Name of Clinical Laboratory: MEDICUS DIAGNOSTICS AND MEDICAL CLINICS-SARA BRANCH

Mode of Payment:

Cash Check Over the Counter Bank Transaction

2021 NEQAS-CC PARTICIPATION FEE:

P 8,000.00
CHECK payment shall be made payable to
LUNG CENTER OF THE PHILIPPINES
 Land Bank Account Number: 07-02105587
*Send this Form to LCP-NRL thru courier