Republic of the Philippines

SOCIAL SECURITY SYSTEM

MED-01688 06-2022
MEDICAL CERTIFICATE
THIS FORM MAY BE REPRODUCED AND IS NOT FOR SALE. THIS CAN ALSO BE DOWNLOADED THRU THE SSS WEBSITE AT www.sss.gov.ph
Please read the instructions below before filling out this form Use black ink only.
PART I - TO BE FILLED OUT BY MEMBER
SS NUMBER NAME (LAST NAME) (MIDDLE NAME) (SUFFIX)
I
(FIRST NAME)

I
0 I 4 2I 6 I 4 I 9I 6 I 2 I 4 3 ZARSUELO MANUEL
PART II - TO BE FILLED OUT BY ATTENDING PHYSICIAN
FLORIDO

A. ILLNESS/INJURY DETAILS
DIAGNOSIS

HISTORY OF PRESENT ILLNESS/INJURY

PERTINENT PHYSICAL EXAMINATION FINDINGS

DIAGNOSTIC/LABORATORY PROCEDURE/S DONE, IF ANY (Indicate date testis was/were done)

OPERATION/S DONE RELATED TO DIAGNOSIS, IF ANY (Indicate date/s of operation)

B. CONFINEMENT DETAILS
PLACE OF CONFINEMENT
□ HOME 0 HOSPITAL ST. ANNE GENERAL HOSPITAL INC. P.GOMEZ EXT. REDV IBABANG DUPAY LUCENA CITY
(Name and Address of Hospital)

D Still confined D Already discharged

1 I 0I 0I 5 I 2I 0I 2 I 3 I I 1I 0 I 0I 7I 2I 0I 2I 3 I
DATE ADMITTED (MM/DD/YYYY) DATE DISCHARGED (MM/DDIYYYY)

C. CERTIFICATION

..
I certify to the following:
That I have seen and examined the above-named patient
That the information in this form are true and correct
. That the illness/injury
D (For Disability) is permanent in nature.
D (For Sickness) confinement including recuperation period may last days.
(No. of days)

This certificate is issued for whatever purpose it may serve with regards to the SSS medical claim by the patient.

10-07-2023
SIGNATURE OF ATTENDING PHYSICIAN DATE ACCOMPLISHED
PRC NUMBER (IF APPLICABLE) NAME OF PHYSICIAN (LAST NAME) (FIRST NAME) (MIDDLE NAME) (SUFFIX)
GARCIA JONATHAN MENDOZA
CLINIC/HOSPITAL ADDRESS (RMIFLR/UNIT NO. & BLDG. NAME) (HOUSE/LOT & BLK NO) (STREET NAME) TELEPHONE/MOBILE NUMBER
P. GOMEZ EXT. RED V (042_ 710- 35 06 / 22 18
(SUBDIVISION) (BARANGAYIDISTRICTILOCALITY) (CITY/MUNICIPALITY) (PROVINCE) POSTAL CODE
BRGY. IBABANG DUPAY LUCENA CITY QUEZON 4301

INSTRUCTIONS
1. The member's attending physician shall accomplish this form in one (1) copy.
2. Fill-out and check all applicable items.
3. PRC number is not required for physician practicing abroad.
Medical Certificate Page 1 of 1