Republic of the Phiippines PHILIPPINE HEALTH INSURANCE CORPORATION Ena CMe HEALTH INSURANCE CF Storms nettanit MD era MEMBER DATA RECORD e MEMBER INFORMATION = — Phitttealth Identification Number (PIN): 020509763071 Member Category FORMAL ECONOMY NHTS Coverage Sub-Category PRIVATE Efiectvity Period FERNANDO, MICHAEL ANGELO DE QUIROZ c BGY 46, PASAY CITY, FOURTH DIST, 1200 Foreign Address : NA Sex Male Date of Birth o4/or/t995 : Place of Binh asay cy ¢ Contact No, (Foreign): NIA Civil Status SINGLE (Local) Tax Identification Ni 818216626 EMPLOYER/ORGANIZED GR aan Priealth Number (PENPOGN) 1007000008005 Name of Employer/Organized Group: SERBIZ MULTI PURPOSE COOPERATIVE Business Address {NIT 20) SAN BUENA BLOG 9 SHAW BLVD, SAN ANTONI, FASIGCTY, SECONDDOISTRNT Telephone Number 045 4553381 Tax Identification Number DEPENDENT INFORMATION om | Middle Name (O DECLARED DEPENDENTIS| A c NOTHING FOLLOWS *** Tse] Reston [Date afaiah . c i LEILANIE CHERRILINA JOY V, ASPRER, M.D. io OIC - Branch Manager NCR South Las Pitas . c Paalala : Basahin ang nilalaman ng MDR. Kung may kulang o mall, balk agad upang maldagdag o malwvast.Ingatan ang onhinal na kopya at huwag ibigay kahit kanino. Kung sakaling gagamit at makikinabang ng benepisyo, magh gay ng kopya sa pital. meno creer fhe MOR Soi thare be ay da deepak bck aed ore the ee Tae go art Prove pocepy host n ase conser and aanet bevels), This is a system generated report. Signature is not required. % ¢