Republic of the Philippines Province of Isabela CITY OF CAUAYAN a CITY SOCIAL WELFARE AND DEVELOPMENT OFFICE Inter-Agency Referral Form Date Jygl 20, 9023 LELYN P. TULPO a zr , veo Asam May ,,we _ refer. to_—your , good office for assistance our client yas” Reade: Thain, Z_years old, and aresident of_Ltrante 7 ‘Cavayan City, abela. Client hos been provided by our agency with pe However, there ore other needs, problems and concems expressed by the above named client which we believe that your agency is in a better position to respond. Hence, we ore refering him/her for: Further Assessment as basis for the provision of Appropriate’ Intervention Provision of Necessary Support Services ‘Counseling Financial Assistance ‘Transportation Assistance ». Burial Assistance Medical Assistance Livelihood Assistance Legal Assistance Legal Counsel Others (specity} We will appreciate if we shall be informed of the actions your office has taken for our guidance. ‘Thank you for your untiring and continuing suppor to the cisadvaniaged ciieniele. Very truly yours, RODFL' go) RSW City Social Welfare and Development Officer Torn Ne. SwrO-0092A Address Cc. Age: 0. ci stats Educ. Ati 1. FAMILY COMPOSITION: CITY OF CAUAYAN Republic of the Philippines Province of Isabela ©) CITY SOCIAL WELFARE AND. DEVELOPMENT OFFICE ABSTRACT CASE STUDY REPORT Win ax, Occupation |. Relationship fo Clanti__ Aowaimald SMe oe — etc oemeht age Rel. 10 Client CiviStatus | Educ, Atin't | Occupation/ Monthly Income _| [ Name | Dregne t ED: lM. PROBLEM PRESENTE A. Other Sources of Income: Food suppor from relatives _ TT tactyard Garden (Others: Retlfement/saiary Backyard Ivestock raising 8. Background Information: Housing & other living cons Housing Structure: _Mokeshi iit/Djapidated —_light Materiql_Concrete_7 Lot; Owned __Amortized ~Shared ter Educational assstance/scholarship grant Uightng: Kerosene Lamp __Candle Electricity | “Owned _shared) Water source: Deep well ,_Artesian well__Natural spring __Zocal Water District V. DIAGNOSTIC IMPRESSION: "Family income fs just enough to meet basic needs Family's internal resources had been exhausted need to restore heal Unless assisted, ness may worsen ar th condi ition of the client to restore her/his social functioning nd aggravate family's economic condition to be supported by extemal resources others: VI. EVALUATION/RECOMMENDATION: Lon the information. the herein client is found eligible for ‘Medical / Financial Assistance /Mealcation/Hospital bil payment) —olners: tion: Cones Rented __shared_Squatter _Caretoker en ht cer “are hereby recommend fo avail of said services in your prestigious insttution/Agency/Office with an ‘utmost consideration of the family's economic plight. NOTED BY: g hy \. ANCHETA, RSW RODELYN City Social Welfare and Development Officer FORM NO. SWD-002-1 Prepared by: HoserTaL ou,Republic of the Philippines Province of Isabela CAUAYAN DISTRICT HOSPITAL Cauayan City, Date: September 19, 2023 PROMISSORY LETTER |, ROSA TUMALIUAN of Brgy. Minante 1, Cauayan city,Isabela hereby promise to pay the incurred balance (hospital bill) of my patient DIEGO _C, TUMALIVAN admitted on September 4, 2023 to September 5,2023 amounting to TWO THOUSAND SEVEN HUNDRED TWENTY PESOS ONLY (Php 2.720.00) on or before September 22, 2023. Name and Signature: Los; b worn cluren ROSA TUMALIVAN Contact: 09069593878 Relation to patient: Mother APPROVED: RHODA JACQUELINE P. ont fron FPSMS- Chief of HospitalRoom v corres 2 One Mi TTS spores: power | tant Ur} Date Discharged: “G4 15 COST OF SERVICES RENDERED DD swe 0 pv (CJ mepicane ‘Amount fncess eT Covered By Charge to HOSPITAL PHIC Medicare Patient cn (0) wssoratony ree oN ep Pnp_\ 047 (0) ray /ecs ree Sie oa a axe OO menicines 2S (D surpues ot C1 once consumerion = (C1) ceuverr Room Fee [D) operatine ROOM Fee D1 00m ano soar (99 1 voctor's wisir CD otners TOTAL COST OF HOSPITALIZATION... meee = 1,998 PHC we ee Name Included (MU) Name Not inchidec(ML) BILLED BY: Certification (DSWD) : Ge Senior Citizen a FRO Others APPROVED: __ RHODA JACQUELINE P. GAFFUD, MD, MHA Chief fo HospitalPROVINCE OF ISABELA CAUAYAN DISTRICT HOSPITAL Cauayan City, isdbels MEDICAL CERTIFICATE SEPTEMBER 1.2023 tae on pnt het aor 70 WHOM IT MAY CONCERN: THIS IS TO CERTIFY that C.TUMALUAN 35 yeasold, MALE, MARRIED, 1 resieat A P1 MINANTE |, CAUAYAN CITY ISABELA »___ BASHA wes examined «= and——treated J confioed in this hospital on / from SEPTEMBER 4, 2023 wo SEPTEMBER 5, 2023 Sorte following: DIAGNOSIS: RIB FRACTURE FRACTURES POSTERIOR WALLS OF THE BILATERAL MAXILLARY MINIMAL BILATERAL FRONTAL SOFT TISSUE EDEMA & HEMATOMA XXKKK NOTE: TRANSFER HOSPITAL OF CHOICE XXKK supplies ied Specialist I License No.: 113550WON, FELI MARLO G. DEJOVA ‘Coramitee on Fnance and Appropriation WON. CHARIE MAE L. MALLILLIN ‘Commitee on Educatlon, Cuture and Republic of the Philippines Province of Isabela j City of Cauayan BARANGAY MINANTE-1 Office of the Punong Barangay BARANGAY ‘INDIGENT’ CERTIFICATION TO WHOM IT MAY CONCERN: THIS IS TO CERTIFY THAT _ P64: THaALIUAY _ of legal age, married/widow/widower/single is a bonafide resident of Purok # ,Zone___ Minante-1, Cauayan City, Isabela ‘This is to Certify further that the above-mentioned name belongs to the low-income members of the community (indigent) with per annum earnings of more or less Thirty Thousand Pesos (Php 30,000.00) that could hardly meet the fundamental living requirements of the family. This Certification is being issued upon due request of the above- named person for whatever legal purpose it may best serve the interested party. DONE this 4 _ day of Office of the Punong Barangay, Minant won Pasa x. Punong Barangay BY: FELT willy DE JOYA Brgy. Kagawad on duty NOT VALID WHEN PHOTOCOPIED AND WITHOUT DRY SEAL