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    b 2305 d 0045104

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    6 views3 pages

    B 2305 D 0045104

    Uploaded by

    nicolaus copernicus

    Copyright:

    © All Rights Reserved
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    Intellicare pew conroreneesoe —WIIUILIIAINEIIM 3 . amens ® Qut-Patient Consultation (RCS 1) Loz No. 8230500045104 VALID UNTIL: 05/25/2023 [Name ofPatent “ALWARIO GRAVIDEZ PARCO. fanCade: a2s08D00ast0a [RCS Date 0672272023 12:00:00 AN [Sard Number: 1495-0000.0579-1006 ospita/Cinic ST. LNE'S MEDICAL CEMTER }kecount ttumbor: 80:00-08174.00473.00 rth Dato: oszer904 [Company R. MANABAT 8.C0. lContactge: 27 [vat 06/46/2029 TO a6it512073 Ser |ncusion: |PEC Limit: 170,000 lexetuston: ax Limit: 170,000 [Room andBoarc: REGULAR PRIVATE (Coordinator: [iegnocis: Focommondation: ALMUARIO GRAVIDEZ PARCO ATIENZA, NOEL DE JESUS Pareierbet Pirie Nare are Signa Requesting Prien Coonsior Haine ava Sgro ‘Kindy note that f you decide not to sign this document INTELLICARE will not be able to process your requested transzotion DATA PRIVACY CONSENT & WAIVER | tne undesignes, neve read the foregoing statement and hereby express my consent tothe above, |furher understand (a) the reasons forthe collection, processing, and infermetion | provide and thet withnolding orfelstying informetion might ac eosirt the best interests cf my assessment. | so ackrowiedge thatthe Company has ard Will sinays tale commercially easoneble steps io protect anc msinizin the confidential nature of my pesoral information in socordance with is apalicable vay policies. I hereby afm my right te be informed, object to prozesing, acces and rectify, suspend oc withdraw my information, nd beindemnfied i case of damages Pursuant tothe provisons of Phippine Osta Privacy Lav, cinerapalicable laws, rules and regulators. | mewse, sonowiecge tnat allot ne proceaures indated In this cooument tad been done. | promle 12 pay for any prececure and professional tess rot expt covered by the provisiore of the Health Senioe Group Corporate Agresmant. Futhermore, by virtue ofthc undertaking, | hereby render the Company fre fom ony liability on the cellection ofthe soquted non-coverable charges (Le exces in limits, exclusions, ic), | fully understand that in instances wherein payables were not sattled upen avsilment, Iwill be suajectad to adit cocumentation and will be charped of administrative fees a: spplicabl, ALMARIO GRAVIDEZPARCO 06/22/2023 10.0720 AM Name and Signature of Member Date ST. LUKE'S MEDICAL CENTER /ATIENZA, NOEL DE JESUS Name ot Hospital Doctor CCondentaty Notice: nteicere will not dsclese any Informstion obtained In Ihe conduct of tne evalustion except as otfenvise provides Nerein, subject 19 the {Sour permission or asrequited by law Intelicare 7h Foo: Felize Bldg. V.A. Rufino Steet, Legazpi Village Makati City ‘Tel, 789-4000 For TEXT ONLY emart 0920-981-8452) sur-0822.98'-2925)globe-2917-808-2602) ‘CALL ONLY sman-0920.970-4724)eur-0822-297-2957)globe-1917-41-4896) MMII IntellicareY __reteratconrersneettor lll vouswrelicerssancrse: } —_ QUt-Patient Consultation (RCS 1) Log No.: B2305D0045104 VALID UNTIL: 05/25/2023 [ame ofPatient "ALMARIO GRAVIDEZ PARCO. [ApGode 8230500045104 [RCS Dale._0572212023 17.00.00 AM [Gard Number. 1195-0000-0579-1008 [Hospital/Cinic: ST. LUKE'S MEDICAL CENTER lkccount number: 80.00-08174-00473.00 laitn Date: 06281994 |Company: RG. MANABAT 8.CO. lace: 27 \vatiaiy: 06/16/2022 10 06/15/2023 sex [ncusion PEC Limit 470,000 Max Lire: +70,000 fPxcusion: [Room and Boarc: REGULAR PRIVATE (Coordinator. (Diagnosis: iecommendation: ALMARIO GRAVIDEZ PARCO ATIENZA, NOEL DE JESUS Parent hlember rites Name ard Signal Requesting Physician Coortinstors Name and Signature DATA PRIVACY CONSENT & WAIVER. | the undesignec, heve read the foregoing statement and hereby express my consent tothe above, |urher understand (a the reasons forthe collection, procesting, and discosure of my inforstion ard the ways in which sid Infomation may be used, snd | agree to seid usage and discoswe; and that b) its my choice as to what Information | provige and thet witnolaing ortalstying nfometion might 2c against he test interes ct my assessment | abo ackrowedge Mat tne Company has ara Policies | hereby afm my right te be informed, obec to prosenting, scams and rectify, suspend oF withdraw my information. and be indemnified in case of damages Pursuant tothe provisons of Philippine Dsta Privacy Lav, cher apalicable laws rules and regulations. ‘OTHER UNDERTAKINGS: | ewes, scnowlecge that all ofthe procedures indisated inthis cooument nad besn done. | promise t» pay for any procecure and profesional fess rot expicily ‘overee by the provisions of the Hasln Service /Group Corporate Agreement. Furhemoe, by virtue of tris underating. | harsby rend the Company free fom any Habilty on tne collection of ne aoquied nor-coverable caaiges (Le exces In limls, clusions, ec), | fully understand that in Instances when payables were not Name and Signatue of Member Date ST. LUKE'S MEDICAL CENTER /ATIENZA, NOEL DE JESUS Name of Hospital /Doctor Confidentiality Notice: Intelicere will not disclose any informstion obtained in the conduct of the evalustion except as otherwise provided hersin, subject 19 the provisions of the Date Prvacy Act. Further, Intlisae quarantass that infermation that can be identified with you wll remain confidential and will e dislosed any with {your permission or as required by iow. Intelicare Th Foot Felize Blag.,V-A. Rufino Stee, Legazpi Vilage Maka Ciy ‘#T

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