Republic of the Philippines (102513227296)

PHILIPPINE HEALTH INSURANCE CORPORATION

ANST Bldg 3, Alternate Road, Legaspi City 4500
(052) 481 5596 (052) 481 5597 (fax) (052) 481 5598
www.philhealth.gov.ph

MEMBER DATA RECORD

MEMBER BASIC INFORMATION
PhilHealth Identification Number (PIN): 102513227296 PhilSys Number : :
Member Category : DIRECT CONTRIBUTOR -
EMPLOYED PRIVATE NHTS Coverage : N/A
Validity Period : N/A

BELLEN, ERROCEL SHANE DOLOR

ZONE 2 TAPAZ COMPOUND BALATAS, NAGA CITY, CAMARINES SUR - 4400

Foreign Address : N/A Sex : FEMALE

Date of Birth : 11/7/1997
Place of Birth : NAGA CITY, CAMARINES SUR
Contact No. (Foreign) : N/A Civil Status : MARRIED
(Local) : /09777428657 Tax Identification Number:
EMPLOYER/ENTITY INFORMATION

Philhealth Number (PEN/POGN) : 200374302428

Name of Employer/Organized Group : INTERNATIONAL SOS (PHILS) INC

Business Address : 28F WEST TOWER PHIL STOCK EXCHANGE CENTER EXCHANGE RD ORTIGAS CENTER , PASIG CITY
SECOND DISTRICT
Telephone Number : 6370700 Employment Status: EMPLOYED
Tax Identification Number : 004967619000 Date : 6/1/2019

DEPENDENT INFORMATION
PIN Surname Given Name Middle Name Sex Relation Date of Birth

*** NO DECLARED DEPENDENT/S ***

HENRY V. ALMANON
REGIONAL VICE PRESIDENT
Philhealth Regional Office - V Legaspi City

Paalala : Basahin ang nilalaman ng MDR. Kung may kulang o mali, ibalik agad upang maidagdag o maiwasto. Ingatan ang orihinal na
kopya at huwag ibigay kahit kanino. Kung sakaling gagamit at makikinabang ng benepisyo, magbigay ng kopya sa ospital.Read the
(Reminder:
contents of the MDR. Should there be any data discrepancies, return it back to amend or rectify the error. Take good care of the MDR and do not hand it over to anybody.
Provide photocopy to hospital in case of confinement and availment of benefits.)
Printed At :
This is a system generated report. Signature is not required. Naga City, Camarines Sur - ALDP Commercial Complex, Roxas Ave., Naga City
11/12/2021 1:35:45 PM30202910 20350302 6/6/2018 / 30202910 11/5/2021