“This form may be reproduced and is NOT FOR SALE PhilHealth che Your Porter in Health revised November 2013, - poe err Ts IMPORTANT REMIDERS: Arsies ere ee es Fs en tee ay nr aerate a PART |= HEALTH CARE INSTITUTION (HT) FORMATION 1. Philteaith Accrediation Number (PAN) of Hesith Care Institution; | 1 L140 1d 4 J 2. Mame of Health Care institution: ‘SAN CARLOS CITY HOSPITAL 3. -Address:_HOA. STA. ANA ROAD (CZ ROAD), ORGY. PALAMPAS, SAN_HEGROS OCCIDENTAL Transtar ea carenceane rae ‘PART Il- PATIENT CONFINEMENT INFORMATION” 3. Name of Patient:_LAMPUTE APRIL JOY SARIMONG ae Traore TREE RT — Wao oars DORE RPT 2. Was patient referred by another Health Care institution (HCI)? Ln Ces Tao RN ET Tiga ce — Sa % Confinement Period: 2. Oate Admitted: (210) — 216) (2101210) b. Time admitted: 042): 27) ant conecicores: (TB, 60, -2672,0, a rmeouerree Qo Claw fara epee Bleep bee sg 1 ym giv Eolas Een Faas [Et transterredmeterreds [le Hemencrared Agent wes Advice i udeaeeoy Boose ses te tent ES 5:1ype of Accomodation: [Z].Prvate [T]p,non-pvte(chanty/service & Admission Diagnosisies: T/C PROBABLE CovID 7. Discharge Diagnosisies: (Use adetonal CF2s W necessary: ‘opens reo oceans Poses Scoie osteat mace awa COPRMED CMD 1 _uOF) -sonenare Ip} c191P¢ _10-/(-2020 Left [Right [7] oth Dawns pepe “ie sents ter [rise 5 seth pond edn = e Lett [7] Right [FF] eotn tere [Right [7] Both Lett F)right [7] otn tert F}rignt F) goth Lert riche [7] soth Lert Fright [7] soth tert [Fright [F] goth Lett [Fright [7] sath tere Fright F) sotn tert [Fright [7] goth tert F]right ) oth tere Fright [7] sotn Ler [Fright [7] Both Both tere F}rignt F) goth Hemorlyss Peritonea! Dialysis Radiotherapy (NAC) Blood Transfusion ——__ Brachytherapy a RS RE ‘chemotherapy ee eS Radiotherapy (COBALT) Single Debridement — b.forzienet Pacage 2. Benefit Package Code! Du bate: &. Fer Mor Pcage ensmaste fot amr ot re sai oeceh ? : 2 ‘ 4: Fertaors acne] intensive Phase [-] Nantenance Phase oem o any Im (ects inm rr wen te toning deve face were vn) [ ROTE And Rabies Vosine Tan Ries immunogen (IG) ] Day 0 ARV, Day 3 ARV. Day 7 ARV RIG ‘Others (Specify) 3 ‘ra neweon recieve] steal Newtbom Care [] Newborn Harog Screening Test] Newborn Scseeng res a rena et | carer en fessor eworn Care Packan chek appa boxes ne i tre] TF recite diving or rewbom_] Tet card dameing [-] weighing othe newbora [-] 806 vcchator TL eons 8 vaccination Exty sintostincontat__[] eve propnyinis_[] vtaminkaciminstration []¥ersesestg ot matey rey rnstnagkiton 3 FerOwpotent HVAIDS Teeiment Package Laboratory numberr 2 Forno Paiag,envarate ow ates prenatal check ops [check Wapphicable Penn ack us |: ForcataacPacone. [| check i applicable cataract he sathoration Nurbe, or wiraocular Lens Seater [ Joresent [Z] Absent ‘arwmty: —___[porye: stterne:__ontetexorton: Jno ye: st Die ot spain | Fermet Oxnstetin Pacoge, [] ene if appiable OEGE tts awieas ou, a |‘PATIENT: LAMPUTE, APRIL. JOY SARIMONG - (CONT) 7] Ne copey ontop f Paes Benet Ah gay on ap ef itetn Senet No Copy on ta f Pitt Benet th Copa) ontop Piet Bene P No copay on tp of ath ene ‘Spare Over Pad ae mt oy ontop of Piety Bent ae ate Sone: : ren ve ‘PART Til - CERTIFICATION OF CONSUMPTION OF BENEFITS AND CONSENT To ACCESS PATIENT RECORD/S NOTE: Merb shou signet ater the applet chares have buen EO |A.CERTIFICATION OF CONSUMPTION OF BENEFTTS D7 Piteats tenet is enough to cover Ht and PF charges. : No purchase of drugs/mecicine supplies agnostics and co-pay for professional fees bythe member/patient. Tet Ac ge TlH Cao Fe al Petes! os Gard Ta ] The eet fe nonbonded pro copy OR te Bae ote meas el comply cosaned BUT ‘ih prise er rad pls gross 9 3) Teal or re flog ae ‘Total Actual “| Amount after Aaplication of Philhesith “Amount after Phtheaith Deduction Gove” | “Cacom termes | "Bon acne, Sr Cosa) Tl rath re ‘Amount? 28,042.80 Instn Fees L2H In Paid by (Check tat apps) 114,003.00 = c 7 ep -PCSO, Promissory note, etc.) Taal tes ‘amount P 0.00 reer 4 : wee ANH LBEER | IETS tse roca (1) WentePoter | 40 |_ Drees) [Doth i, PS, robs ee) 0) Pudsey NOT elie nthe Heath Cre ston are Tt cos ot prs ox ruses der medal anes bam] 77) wong T= he atetmenber wine he Ht avg cotneret Divone () toatanent @ Taal ost dagosifaertry exratons pero : {pater/member dare without the HI rng covert TD none [1] reat amount P "NOTE: Total Atul Chges shoud bast on Statement of Account (SoA) ‘8 CONSENT TO ACCESS PATIENT RECORD/S | hereby consert to the examination by Phieath of the patent's medal record forthe scl purpose of vsifyng the veracy ofthis cai. hereby hold Phitealth or any of ts oficgs, employees and/or representatives free from any and al bles relave tothe heren- mentioned consent which I have vountariyand wi ver GD sase Ooms O) parre ‘I patet/epresentative Is unable to wre, te Det rch hambmar: Pate represent Ta 1 a eee econ 1 Ptere is napacated heck te poopie bx 1 Patient] nemreseriative »ART IV - CERTIFICATION OF HEALTH | ceri that series rendered were recorded inthe patients chrt end healh cae insuton records and that the herein formation ven ae true and core. BERNADS HAY, CPA, MPA es. MAAIV Date signed: 4.2) “435, L.Q.20, ~ Sirti Over Mb Nae of ‘a Cape 7 Ossnion ‘Authorized HCL Representative