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Republic of the Philippines

PROVINCE OF ZAMBOANGA DEL NORTE


LABASON DISTRICT HOSPITAL
Labason, Zamboanga del Norte

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.

MARANISBA A. INSONG, RSW


MSWO/SWDO

0013892
License Number

Republic of the Philippines


PROVINCE OF ZAMBOANGA DEL NORTE
LABASON DISTRICT HOSPITAL
Labason, Zamboanga del Norte

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.

MARANISBA A. INSONG, RSW


MSWO/SWDO

0013892
License Number

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