BSB Form No. 2-B s.

2023

Republic of the Philippines

Province of Leyte
MUNICIPALITY OF BURAUEN

APPLICATION FOR MEDICAL OR HOSPITAL ASSISTANCE

Pursuant to the Data Privacy Act of 2012 (Republic Act No. 10173), I hereby give my consent to the Municipal Government of Burauen
to process my personal information and sensitive personal information for my application for medical or hospital assistance. I understand
that the processing shall be limited to the purpose speci ed.

NAME OF BARANGAY OFFICIAL : ____________________________________

POSITION : ____________________________________

BARANGAY : ____________________________________

CITY/MUNICIPALITY : ____________________________________

PROVINCE : ____________________________________

DATE OF ELECTION/APPOINTMENT : ____________________________________

DIAGNOSIS : ____________________________________

HOSPITAL’S NAME : ____________________________________

NUMBER OF DAYS CONFINED : ____________________________________

______________________________________________
(Signature over Printed Name of Claimant)

___________________________
(Date Accomplished)

Evaluation —————————————————————————————————————————————

DENIED due to : _____________________________________________ Recommending Approval

FOR COMPLETION OF REQUIRED DOCUMENTS:

_____________________________________________________________ ________________________________________
RECOMMENDED FOR APPROVAL Signature over Printed Name
Recommended Amount: ₱ 2,000.00 ₱ 3,000.00
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