Version 17.

0 December 1, 2022

Medical Assistance Application Form

11th Floor Robinsons Cybergate Plaza, EDSA corner
Pioneer St., Mandaluyong City
Contact # (02) 8370-1716 ; 8370-1719
Email Address: pad@ovp.gov.ph

Pursuant to the Data Privacy Act of 2012 (Republic Act 10173), I hereby give my consent to Date of Interview
the Office of the Vice President (OVP) to process my personal information and sensitive
personal information for my application for medical assistance. I understand that the Record No.
processing shall be limited to the purpose specified.

I understand that I can only avail of the medical assistance as provided under OVP guidelines
only once in every 6 months and I will comply with these requirements.

Name of Patient FIRST NAME MIDDLE NAME LAST NAME

Date of Birth MONTH, DAY, YEAR Age Sex Contact Number

Male Female

Current Address

Diagnosis Educational Attainment

Dialysis Center/ DOH

Hospital’s Name Occupation
Family Monthly Income Signature

Household Composition

Name Age Sex Relationship Civil Educational Occupation Daily/Monthly

to Patient Status Attainment Income

Details of Authorized Representative

Name of Authorized FIRST NAME MIDDLE NAME LAST NAME

Representative

Relationship to Age Sex Signature

the Patient Male Female

Contact Number E-mail Address

Evaluation TO BE FILLED OUT BY OVP PERSONNEL

DENIED Recommending Approval

Due to availment of the medical assistance within six (6) months from the date
of this application
DATE OF LAST AVAILMENT: ________________________________
Invalid/Non-compliant Documents
Blacklisted due to fraud
SIGNATURE OVER PRINTED NAME
Others: ____________________________

FOR COMPLETION OF REQUIRED DOCUMENTS

Please return on: Actual Date of Return:

Details/Instructions to be placed on the checklist at the back of this form.

RECOMMENDED FOR APPROVAL

For Credit Line Requested Amount: ________________
For Fund Transfer For: _____________________________
For issuance of Guarantee Letter Recommended Amount: _____________
Remarks: _________________________

PAALALA: LAHAT PO NG MGA PORMA AT PROGRAMA NG TANGGAPAN NG PANGALAWANG PANGULO

AY LIBRE AT WALANG BAYAD.
 PATIENT/REPRESENTATIVE WAIVER FORM

Ako si ____________________________, (pasyente / representative), ay nangangako na ang lahat

ng impormasyon at dokumentong aking isusumite ay tunay at totoo. Naiintindihan ko na ang aking
ipinasang aplikasyon ay dadaan muna sa pagsusuri upang makumpirma ang katunayan ng mga
dokumento.

Anumang mapatunayang kasinungalingan o pag gamit ng mga pekeng dokumento ay magdudulot

ng disqualification o pagkansela ng aplikasyon para sa Medical Assistance Program at maaaring
magresulta sa criminal o civil liability gaya ng pagkakulong at multa.

SIGNATURE OVER PRINTED NAME

DATE

OFFICE OF THE VICE PRESIDENT

11th Floor Robinsons Cybergate Plaza, EDSA corner Pioneer St., Mandaluyong City
Contact # (02) 8370-1716 ; 8370-1719
Email Address: pad@ovp.gov.ph

PAALALA: LAHAT PO NG MGA PORMA AT PROGRAMA NG TANGGAPAN NG PANGALAWANG PANGULO

AY LIBRE AT WALANG BAYAD.
 General Requirements List of Valid IDs
1. Original Copy of the Medical Application • Driver’s License
Form. Dated and signed within three (3) ● Solo Parent ID
months from date of application. ● NBI Clearance / ID
2. Original Copy of the Social Case Study ● TIN ID
Report or Certificate of Indigency/ ● Passport
Eligibility. should be issued by a DSWD, ● UMID/GSIS/SSS ID
PSWDO, CSWDO, or MSWDO Social ● PhilHealth ID
Worker and addressed to the OVP. ● Voter’s Certification
3. Original/Certified Copy of Medical ● Police Clearance / ID
Records (e.g., Medical/Clinical Abstract, ● 4Ps ID
Medical Certificate) ● PRC ID
4. Photocopy of one (1) valid Identification ● Postal ID
Card (ID) of: ● PWD ID
a. Patient ● Senior Citizen ID
b. Authorized representative if any ● Barangay ID
● Philippine Identification System (National ID)

Alternative IDs for Minors:

● Registered Birth Certificate
● School ID (currently enrolled)
● Barangay ID
Certification issued by the hospital in case of
newborns

Case Requirements and Conditions

Chemotherapy, Radiation Therapy, 1. Treatment Protocol - Dated not more than
Brachytherapy three (3) months prior to the date of
application
Hospitalization 1.1 If still admitted, the latest Statement of
Account will be required. PhilHealth
Benefits and other mandatory discounts must
already be deducted.
1.2 If discharged, the updated Statement of
Account and Promissory Note will be
required.
Medicines / Implant / Medical Equipment / 1. Price Quotation from an OVP Service
Assistive Device Provider or any service provider that is willing
to accept Guarantee Letters.
2. Prescription - Dated not more than three (3)
months prior to the date of the application.
3. Authorization Letter signed by the patient, if
the patient will not be able to personally
receive the medicine/implant/medical
equipment/assistive device.
Diagnostic Procedure/ Dialysis For Dialysis Treatment:
1. Must have a Certification that PhilHealth
benefits have been exhausted
For Diagnostic Procedure:
1. Preferred in Gov’t Hospital, provide
Justification for private institutions (e.g.,
unavailability of procedure in Gov’t Hospital)
Wheelchair 1. Handwritten Personal Letter by the
patient addressed to the OVP/ Vice President
2. Certification from the attending physician that
the patient is in need of a wheelchair

PAALALA: LAHAT PO NG MGA PORMA AT PROGRAMA NG TANGGAPAN NG PANGALAWANG PANGULO

AY LIBRE AT WALANG BAYAD.