TeNOTFORSALE Republic the Philipines ’ @ PHILIPPINE HEALTH INSURANCE CORPORATION - PhilHealth ‘Gta Centre 709 Shaw Bovlevai, aig iy Pe call Center (02) 441-7442 «Trine (02) 41-7644 (Claim Form 2) nal: actionentere hie gor e elton ec IMPORTANT REMINDERS: FLEAS WRITE N CATAL LETTERS AND CHECK THE APPROPRATE Thier together with other supporting document shoul be fled thi sity (calendar days rom date os ‘Aliormation els nd tick axes requtedin this om ae necessary. Clam forms with ncomplts oman shal tbe process. FALSE/INCORRECT INFORMATION OR MISREPRESENTATION SHALL BE SUBJECT TO CRIMINAL, CIVIL OR ADMINISTRATIVE LIABILITIES eke G ecru 4.PhilHealth Accreditation Number (PAN) of Health Care Institution: ,, 0) 610,11, 7)5)6 2.Name of Health Care institution: SAN CARLOS CITY HOSPITAL 3.Address: HOA STA ANA ROAD BRGY. PALAMPAS SAN CARLOS CITY NEGROS OCCIDENTAL 7) 1. Name of Patient: Lat Nam TO vs f Name .confinementPeriod: is nits fOr Alay O60, 5 B22, Om Ao Eonar 2 LOB 1% 840, time ischange LR £2, Ow Pu [it tenseineitered pages Sr Hore/Discharged Against Medical Advi sf ee ae sme ttteguneelaestine Ena om oe 5.Type of Accomodation: [7] Pst: Nor frate haryeree) = 6.Admission Diagnosisjes: VO PRORMAUE COVD adorl CF reese IeDIDCodefs Relate Proclear on Code |" DateolFroceduie __tatealty ebeck opal UOF! \7pebehlee WN, hy OMG" ZOGO let “ TEM a 'e lo: HER Veh Tie. 87 oe aly Paetmonn cet aS eho ae aS = setae eee ees tet bahar ap esand ericsson ori For moth aap sepa som Gg toed Tnsson (Co rtheapy unac a ae ee [Ey siotedettemert fu are fiance reewtimansase 7 Chaiyp AI For MCP actos eum four dts of petal checkup) rrenorseadage LC] wetiee E] tinermarae oe each dts mde we te ello doses cc reper a Atala tn Ral ay3anv bayrany te ners (Speci) ~O (awe PhilHealth Benefits: eo 10 oF RUS:ON oo of PhiMeath Benet P Cr A.CERTIFICATION OF CONSUMPTION OF BENEFITS: Total Health Cave Ins = $e ~ [Ay Iban ners olan pry Oat el eben BA ra TT Total Actual Charge a Philltealth Benefit Amount atter PhilHealth Deductio L (Sao ne cee YFG. wmount P At, OPP. Sumer |, 009.00 | ship | = ee ai ae. a ee | a Toast, 030,Promionyn a | 19, SRY [owes 21 Bev oT eek Futrbsraien E}ino sineritinnnsoreaargarionen EO | Ph ye] Wana ser mbt itor ile sel ds Drove ttanon oe * NOTE: Ya Acual Chrpes tou be kasd on Sananen GI ACOUA ON B.CONSENT TO ACCESS PATIENT RECORD/S: ‘hereby consent to the submission and exominat ficient processing of benefit payment. "ae tr tag ea ee Velwor 6. feo I tion ofthe patient's pertinent medica records forthe purpose of veiying the veracity ofthis clam to effect reson Lah £Fins 28600, soe entatiweto [F) Spou Jews OD sting 5 others spec O Ol rein Representative CovID PATIENT were recorded in the patient's chart and heath care institution records and that te herein information given ore true and correc. INGHAY, CPA, MPA, MAA