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    9 views2 pages

    D2402D0008961

    Uploaded by

    mj digital

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    © All Rights Reserved
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    Intellicare q Referral Control Sheet for NUM 8 NS MTELCTEATICHS PF Qut-Patient Consultation (RCS 1) Loa No.: 240200008964 VALID UNTIL: 02/11/2024 [ame ofPaient TILA PASOBELLO LANGTT [arcade D2407D0008061 | RCS Daie._0710877074 17:00:00 AM [cara Number: 1195-0200-0022-3303 |Account Number: 20-00-07188-02862.00 [Company CGI (PHILIPPINES) INC. [Hospita/Ctinic: CHINESE GENERAL HOSPITAL & MEDICAL CENTER pith Dato: 0807°2000 IContract Age: 23 [vat 08/30/2023 T0 o2rtarno24 sexe [nousion [PEC Limit 350,000 Lexetuston ax Lit 350,000 [oP Stine GC; _SLMC.GC;1P-ER SLMC.6C [Room and Boarc: REGULAR PRIVATE [Coorainator: Piegnosis: FRocommondato [RCS Remarks: LAILA PASOBELLO LANGIT Pareniember Printed Name ard Sighaivre SHARMAINE IVY SUN equaling Piyaiten/Coodinalors Name ard Sighaiae ‘Kindy note that f you decide not to sign this document. INTELLICARE will not be able to process your requested transzotion DATA PRIVACY CONSENT & WAIVER. | the undesignec, neve read the foregoing statement and hereby express my consent tothe above, |furher understand (a) the reasons forthe collection, procesting, ano infermetion | provide and thet withrolding orfelstving informetion might ac eosirt the best interests cf my assessment. | abo ackrowiedge thatthe Company has ard will sivays tale commercially easoneble steps io protect anc msinizin the confidential nature of my pesoral information in sccordance with is apalicable vay policies. I hereby afm my right te be informed, object to prozesing, acces and rectify, suspend oc withdraw my information, nd be indemnified in ease of damages Pursuant tothe provisons of Phippine Osta Privacy Lav, cine apalicable laws rules and regulators. | mewse, sonowiecge tnat allot ne proceaures nated In this cocument tad Deen done. | promile 1 pay for any prececure ana professional tess rot expcity covered by the provisiore ef the Health Senioe Group Corporate Agresmant, Futhemor, by virtue ofthc undertaking, | hereby render the Company fre fom any lability on the cellection ofthe soquted non-coverable charces (Le exces in limits, exclusions, ic), | fully understand that in instances wherein payables were not sattled upen avsilmen, Iwill be suajectad to adit cocumentation and wil Be charped of administrative fees at spplicabl, LAILA PASOBELLO LANGIT 0262026 1:42:15 AM Name and Signature of Member Date (CHINESE GENERAL HOSPITAL & MEDICAL CENTER / SHARMAINE IVY SUN. Name ot Hospital ;Dotor CConndentality Notice: Inteicere will not asclese any Informstion obtained In Ihe conduct of the evalustion except as otfenvise provides nersin, subject 19 the ‘Sour permission or asrequited by Iau ° ‘Tel, 78948000 For TEXT ONLY(emart 0820. ‘CALL CNLY(smer-0820-370-4724) un 0822-381-2967) (glebeO817-861-4854) TS Intellicare | _reteratconrersheet tor ill yousrelicerssanuchse: } — QUt-Patient Consultation (RCS 1) Loa No.: D24020000896+ VALID UNTIL: 02/11/2024 [ame ofPatient LAILA PASOBELLO LANGIT [ApGode 0240200008961 _|[RCS Dale. 02/08/2024 17.00.00 AML [Cara Number. 1195-0200-0022-3303, [HospitallCiinic: CHINESE GENERAL HOSPITAL & MEDICAL CENTER |kccount number: 80.00.07188-02862-00 lartn Date: 08107:2000 |Company: cot (PHILIPPINES) INC. lace: 23, \vatiaiy: 08/3012023 TO oart4i2024 sex [ncusion PEC Limit 360,000 tax Limit: 380,000 [Exclusion [oe stine-cc; ip-SLNC-GC;1P-ER-SLINC-6C [Room and Boarc: REGULAR PRIVATE [Coordinator [piagnosis: Recommendation: LAILA PASOBELLO LANGIT SHARMAINE IVY SUN Farenilember Printed Name ard sigraive Requesting Physician/Coorinstors Name ard Signature DATA PRIVACY CONSENT & WAIVER | the undesignec, heve read the foregoing statement and hereby express my consent tothe above, |furher understand (the reasons forthe collection, procesting, and discosure of my Inforstion ard the ways in which seid Infomation may be usec, snd | agree to seid usage and discoswe; and that b) its my choice as to what Information | proviae and that witnnolaing ortalstying informetion might 2c against he test interess ct my assessment. | abo ackrowedge Mat tne Company has ara Policies | hereby afm my right te be informed, obec to prosenting, scoas and rectify, suspend o: withdraw my information. and be indemnified i case of damages pursuant tothe provisons of Philippine Data Privacy Lav, cher apalicable laws rules and regulations. (OTHER UNDERTAKINGS: | ewe, scnowlecge that all ofthe procedures inated inthis cooument nad been done. | promise t2 pay for any procecure and profesional fess rot axpicily ‘overee by the provisions of the Hesln Service (Group Corporate Agreement. Furhermoe, by virtue ofthis underating. | hereby tend the Company free fom any HaDilty on tne collection of tne aqquied nor-coverable cnaiges (Le exces In lis, clusions, ec). | fully undestand that in Instances wheiein payables were not Name and Signature of Member Date (CHINESE GENERAL HOSPITAL & MEDICAL CENTER / SHARMAINE IVY SUN. Name of Hospital /Doctor Confidentiality Notice: Intelicere will not disclose any informstion obtained in the conduct of the evalustion except as othervise provided hersin, subject to the provisions of the Date Privacy Act. Further, ntlisae quarantass nat infermation that can be identified with you wll remain confidential and will be cisloseg any with {your permusion or as required by law. Intelicare Th Float Felize Blag.,V-A. Rufino Stee, Legazpi Vilage Maka Clty ‘#T

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