li1 - Philippine Health Insurance Corporation
li1 - Philippine Health Insurance Corporation
li1 - Philippine Health Insurance Corporation
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Generic/Brandname<br />
(dose/crip/syrup/injeclililo<br />
Wbv.Slin,'Jn\'}li;mcontcr.l)<br />
Qty<br />
UnitPrice<br />
Actual<br />
Charges<br />
Benefit<br />
TOTAL<br />
PARTIII-X-RAY,LABORATORIES,SUPPLIESANDOTHERS(useadditionalsheetifnecessary)<br />
Particulars<br />
Qty<br />
UnitPrice<br />
Actual<br />
Charges<br />
Phil<strong>Health</strong><br />
Benefit<br />
A.X-Ray(Imaging)<br />
B.Laboratories/Diagnostics<br />
CSuppliesandOthers<br />
? Official receipts for drugs and medicines / supplies purchased by member from external sources as well as laboratory procedures done outbide the<br />
hospital which are necessary for the confinement tie merit are attached are attached to this to this claim. claim.<br />
PART IV - CERTIFICATION OF INSTITUTIONAL HEALTH CARE PROVIDER<br />
I certify that sendees rendered were recorded in the patient's chart and hospital, records and that the herein information given are (rue and correct.<br />
TOTAL<br />
The foregoing items and charges are in compliance with the applicable laws, rules and regulations.<br />
Signature Signature Over Printed Over Name Printed of Authorized Name Representative of Authorized RepresentativeOfficial Capacity / DesignationDate Signed Official {month-day-year)<br />
Capacity/ Designation<br />
II _ II _ II<br />
PART V - CONSENT TO ACCESS PATIENT RECORD/S<br />
I hereby consent to the examination by Phil<strong>Health</strong> of the patient's medical records for the sole purpose of verifying the veracity of this claim<br />
I hereby hold Phil<strong>Health</strong> or any of its officers, employees and/or representatives free from any and all liabilities relative to the herein-mentioned<br />
consent which I have voluntarily and willingly given in connection with this claim for reimbursement before Phil<strong>Health</strong>.<br />
Signature Over Printed Name of Patient<br />
jJ - UJ - U^J<br />
Dale Signed (month-day-year)<br />
ignature Over Printed Name of Patient's Representative<br />
Date Signed (month-day-year)<br />
Reason for Signing on Behalf of the Patent<br />
Q Patient is IncapacitatedQ Other Reasons:<br />
Relationship of the Representative to the Patient<br />
j~| Spcuse r~] Child f~~j Parent r~j Guardian/
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