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CERTIFICATION
This is to certify that _______________________________ has been assessed in accordance with the DOH
Classification on Indigence/DSWS Assessment Tool as:
Financially Capable
Financially Incapable
This certification is issued for the purpose of availment of PhilHealth benefits of the above-named patient
according to the provisions of Republic Act 10924 or the General Appropriations Act of 2019.
Issued on ___________________, 2021 at Labason District Hospital, Labason, Zamboanga del Norte.
0013892
License Number
CERTIFICATION
This is to certify that _______________________________ has been assessed in accordance with the DOH
Classification on Indigence/DSWS Assessment Tool as:
Financially Capable
Financially Incapable
This certification is issued for the purpose of availment of PhilHealth benefits of the above-named patient
according to the provisions of Republic Act 10924 or the General Appropriations Act of 2019.
Issued on ___________________, 2021 at Labason District Hospital, Labason, Zamboanga del Norte.
0013892
License Number