Repub ofthe Pines PHILIPPINE HEALTH INSURANCE Phitieath ARERR in Para Heth i IMPORTANT REMIDERS: sense [TT PLEASE WRITE IN CAPITAL LETTERS AND EMECK THE APPROPRIATE BOXES. ara ‘Allinformation required in ths frm are necessary. Ciim ferme with incomplete information shall not be processed FALSE / INCORRECT INFORMATION OR MISREPRESENTATION SHALL BE SUBJECT TO CRIMINAL, CIVIL OR ADMISITRATIVE LIABILITIES, RIE EUEee) TPEET]-[] 2. Name of Member: 2 LaweuTe LASPER OWN PADUA 2 Phiteakh Identification Number (PIN) of Member: [i ]z]- [5] 2] = 4 PhieathWentneation Number (Pm) of Dependent: TT] [o[ TST aMPuTe APRILIOV wet TO }-ETS-Te Epo] » osteo TP-ER-EEEE] bebe 9. CERTIFICATION OF MEMBER: . " Linder the penalty of atest thatthe formation | rove nhs Form ore accurate to thebestof my nied ZVelnor— Zola] 1 Phileaith Employer Number (PEN): oo 3. Business Name: CITY GOVERNMEKT OF SAN CARLOS 4. CERTIFICATION OF EMPLOYER: [ enarsby, consent fo the submission and examination ofthe patient's pertinent medical records for Ine ee tina eam of 0 er 1edieal records forthe purpose of verlying the veracity of ‘mentioned content which | hase no representatives tree rom any legal Habiltes relative to the herein- iven In connection with ths calm for reimbursement before Shihieni ve sone 170) - TG)- TEP] How Che PhilMeatth Benefits: IED 10 OF AVS Code: 4. Fst case A cusip2 Second Case Rate ech wer recerded nthe patents chart and heath cre titton records 2nd tat the harin information ge "cenit that servces