MEDICAL INFORMATION CENTER (MIC)

LETTER OF GUARANTEE (LOG) Number: 02-8895-3308

PLDT Toll Free: 1-800-10-895-3308
IN-PATIENT Email: mic@etiqa.com.ph

TO: Hospital Name CHINESE GENERAL HOSPITAL AND MEDICAL CENTER LOG NO. IP-2542-32904181
UNIT / DEPARTMENT: DATE: 10/03/2023
TEL. / FAX / EMAIL: 028-7114141 TIME: 02:00 PM
This is to certify that, as of this date, below-mentioned patient is a bonafide member of Etiqa Philippines occupying Room No. at PhP 3,800.00/day/category
REGULAR PRIVATE. He / She is entitled to the limits below under his / her plan and all necessary diagnostic and treatment services subject to the conditions /
limitations specified in the policy.
REMARKS:
PLEASE SEND SUMMARY AND ITEMIZED
SOA PRIOR TO DISCHARGE @ LO@etiqa.com.ph
INITIAL COVERAGE IS UP TO 100K
FOR ANY CONCERN PLEASE CONTACT
LO PAUL ANTHONY PEREZ
Paul.Perez@etiqa.com.ph
COMPANY NAME: MANILA ELECTRIC COMPANY (MERALCO) PRODUCT: MedProtect ___ / MedProtect+ ___ CLASS: 3
PATIENT NAME: JUGAO, TERESITA DATE OF BIRTH: 12/11/1957 AGE: 65
ID CARD NO.: 101-02518-263613-302 EFFECTIVE DATE: 01/01/2023 EXPIRY DATE: 12/31/2023
PRINCIPAL NAME: JUGAO, JASON DATE OF BIRTH: 06/02/1980 AGE: 43
RELATIONSHIP: PARENT ROOM & BOARD ALLOWED (AMOUNT/CATEGORY):
LARGE PRIVATE Max of PHP 2200
ADMISSION DATE & TIME: 10/03/2023 DISCHARGE DATE & TIME: 10/03/2023
INITIAL DIAGNOSIS: FINAL DIAGNOSIS:
(C649) MALIGNANT NEOPLASM OF KIDNEY, EXCEPT RENAL PELVIS, (C649) MALIGNANT NEOPLASM OF KIDNEY, EXCEPT RENAL PELVIS,
UNSPECIFIED SIDE UNSPECIFIED SIDE

PROCEDURE/S DONE/RUV/RVS: MAXIMUM BENEFIT LIMIT:

100,000.00

Accordingly, Etiqa Philippines agrees to pay all expenses incurred during his / her confinement based on our agreement, except the following (MARKED):
Difference in Room & Board PHILHEALTH: REQUIRED
All Incremental Charges of 20% for Hospital OPTIONAL
Excess in Professional Fees / PF of Non-Accredited
Ineligible Miscellaneous / Personal Charges Co-insurance / Co-Pay
Take Home Medicines Corridor Deductible
Professional Fees covered under Etiqa Philippines accredited rate:
Doctor's Name Specialty No. of Visit Amount Total
PLAN MEMBER'S PRIVACY POLICY & CONSENT: I, for myself and on behalf of my dependents, and/or my authorized representative, authorize Etiqa Philippines to process my
personal data, such as, but not limited to, my medical diagnosis/utilization data and to disclose the said personal data to necessary third parties such as, but not limited to, my
employer, accredited network providers, headquarter, reinsurers, group policy holders and auditors. I understand that the processing of my personal data shall be used in servicing my
account which includes, but is not limited, to the following benefits administration, medical treatment, and management of the plan. I agree to receive marketing updates and offers. I
agree to obtain a copy of my records relative to my hospitalization, consultation and treatment or any other medical advice in connection with the benefit/claim availed.
PLAN MEMBER'S UNDERTAKING & REMINDER: Plan Member must sign AFTER availment. Unused LOG should immediately be reported to Etiqa Philippines' Account
Reconciliation Exit Clearance. Final computation of your coverage will be made once Etiqa Philippines' Medical Claims Payables Department adjudicates your claims considering any
of the following: (a) any call-less availment; (b) reimbursement claims; and (c) unprocessed claims that are yet to be billed by the accredited network providers. I agree that any
availment may be denied under circumstances such as concealment and procedures not related to the illness. I agree to settle for billback any incurred ineligible excess charges on
benefits. I render Etiqa Philippines free from any liability on the collection of the acquired excess charges on benefits.
ACCREDITED PROVIDER'S UNDERTAKING & REMINDER:
Accredited Network Provider must sign AFTER COMPLETION OF SERVICE. All procedures/tests must have prior approval from Etiqa Philippines' MIC. For immediate payment,
please submit all bills within 30 calendar days. Accredited Network Provider shall notify Etiqa Philippines if payment is not received within 30 calendar days from receipt of submitted
bills. Send all billing statements and original supporting documents to Etiqa Philippines' Medical Claims Payables Department together with this LOG.

Date & Time Prepared: Conforme:

Issued by: Checked by: Date & Time Faxed:
PAUL ANTHONY PEREZ PAUL ANTHONY PEREZ Signature Over Printed Name of PlanMember and/or
Faxed by: Authorized Representative
Supervisor /
Liaison / MIC Officer Received by: Date & Time:
Team Leader

Original - Etiqa Philippines MedClaim's copy Blue - Hospital's copy Green - Etiqa Philippines MOD's copy