DRF

DIAGNOSTIC REQUEST FORM

Date Issued: MARCH 15, 2024

Patient's Name: ARCEGA, FLORENCE DIANE R.

Contact No.: Age: Sex:
ISLA LIPANA & CO. I.D. No.: 1020-448200 Expiry Date: OCTOBER 16, 2024
Company:
HI-PRECISION DIAGNOSTIC CENTER INC. ORTIGAS
Name of Hospital/Clinic/
Laboratory: Diagnosis:
Examination/Procedure Requested: Date of Procedure:
FBS Amount Limit:
HBA1C Remarks: VALID UNTIL MARCH 25, 2024
LIPID PROFILE NOT VALID FOR DRIVE THRU AND HOME SERVICE
PPE NOT COVERED
BUN
CREATININE PHILHEALTH:

*Please print two (2) copies. Required Not Required

Special diagnostic procedures such as CT Scan, MRI, 2-D Echo, and tests more than ₱1,000 need approval from COCOLIFE at:
Helpline:(02) 8812-9090 or 8396-9000 / Short Messages Services (SMS) or text messaging at 0917-622-2626
Calls and SMS: 0917-536-0962 / 0908-894-7763
Approval is valid for 3 days from the issued date or before expiry date, whichever comes first. If beyond 3 days, please call for re-approval

8716753 / REAPP #:1027844 DAYAN FABONAN

Approval No. Name of Approver (COCOLIFE Representative)

*Member must present other identification (such as driver's license, company/school I.D.) to confirm identity.

UNDERTAKING, PRIVACY POLICY & CONSENT FORM:

By signing this form: (a) I understood and agree to the COCOLIFE Privacy Policy for the purpose of servicing my benefit plan; (b) I or my
next kin hereby consent COCOLIFE, its employees/representative to the collection, processing, storing, disclosure and sharing of my herein
personal data, medical/health information and utilization data from and to its accredited hospitals/clinics/health professionals, and to my
company/employer for purposes of assessing my coverage, administration of benefit plan, processing of any transaction necessary for
the treatment of illness, conduct inquiry and obtain data pertinent to the herein availment, and for other reasonable and legal purposes
related to my plan; (c) acknowledge that the procedures indicated above have been done; (d) promise to pay COCOLIFE all expenses not
covered by the company's benefit plan; (e) render COCOLIFE free from any liability on the collection of the acquired non-coverable charges
e.g. excess in limits, exclusions, etc; (f) fully understand that I will be subjected to billback and adminstrative fees in case I fail to timely pay
availments made outside the coverage of the benefit plan; and (g) COCOLIFE and its employees/representative are hereby released from
any and all liability in accordance hereto.

COCOLIFE HEADOFFICE/ DAYAN FABONAN DR. BITO SOLIMA JR.

Patient/Legal Representative Hospital/Clinic/Coordinator's Representative Attending Physician
if patient is below 18 years Printed Name & Signature Printed Name & Signature
Printed Name & Signature
To facilitate payment, submit copy to COCOLIFE within 30 days.
Note:
COCOLIFE HealthCare Division Please print 2 copies and
8th Floor, Feliza Building, V.A. Rufino St., Legaspi Village, Makati City present it to the respective
doctor's clinic/department.
HEALTHCARE 080-0623-2 Tel. No.: 8813-3000 | Fax No.: 8812-3363