li1 - Philippine Health Insurance Corporation

More documents

Recommendations

Info

Generic/Brandname (dose/crip/syrup/injeclililo Wbv.Slin,'Jn\'}li;mcontcr.l) Qty UnitPrice Actual Charges Benefit TOTAL PARTIII-X-RAY,LABORATORIES,SUPPLIESANDOTHERS(useadditionalsheetifnecessary) Particulars Qty UnitPrice Actual Charges PhilHealth Benefit A.X-Ray(Imaging) B.Laboratories/Diagnostics CSuppliesandOthers ? Official receipts for drugs and medicines / supplies purchased by member from external sources as well as laboratory procedures done outbide the hospital which are necessary for the confinement tie merit are attached are attached to this to this claim. claim. PART IV - CERTIFICATION OF INSTITUTIONAL HEALTH CARE PROVIDER 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. TOTAL The foregoing items and charges are in compliance with the applicable laws, rules and regulations. Signature Signature Over Printed Over Name Printed of Authorized Name Representative of Authorized RepresentativeOfficial Capacity / DesignationDate Signed Official {month-day-year) Capacity/ Designation II _ II _ II PART V - CONSENT TO ACCESS PATIENT RECORD/S I hereby consent to the examination by PhilHealth of the patient's medical records for the sole purpose of verifying the veracity of this claim I hereby hold PhilHealth or any of its officers, employees and/or representatives free from any and all liabilities relative to the herein-mentioned consent which I have voluntarily and willingly given in connection with this claim for reimbursement before PhilHealth. Signature Over Printed Name of Patient jJ - UJ - U^J Dale Signed (month-day-year) ignature Over Printed Name of Patient's Representative Date Signed (month-day-year) Reason for Signing on Behalf of the Patent Q Patient is IncapacitatedQ Other Reasons: Relationship of the Representative to the Patient j~| Spcuse r~] Child f~~j Parent r~j Guardian/
@fc^ PhilHealtn MBramier Your Partner in in Health tieaun(Claim Form) *SPrevised February 2010 IMPORTANT REMINDERS: THIS FORM SHOULO BE FILED TOGETHER WITH PHILHEALTH CLAIM FORMS 1 AMD 2 WITHIN GO CALENDAR DAYS FROM OATE OF DISCHARGE FOR LEVEL 1 FACILITY, THIS FORM SHALL BE REQUIRED FOR ALL BENEFIT CLf.lMS FOR LEVELS 2, 3 AND A FACILITIES, THIS FORM IS REQUIRED IN CASES OF I) EMERGENCY/TRANSFERRED 2) LESS THAN 24 HOURS ADMISSION 3) CASE TYPE 'D' DIAGNOSIS THIS FORM SHALL BE REQUIRED FOR ALL CLAIMS ON MATERNITY CARE PACKAGE. 1 PhilHealth Accreditation No (PAN) - Institutional Health Care Provider:I I 1 I I I I I I | PART I - PATIENT'S CLINICAL RECORD 2. Name of Patient|7~Z. 1 Thr Wrn may be reproduced and is NOT FOR SALE CF3 Last Name, (example. Dela Cruz, Juan Jr, Sipag) 4 Date Admitted Time Admitted. | |AM j |p 5. Date Discharged' Time Discharged I AML|PM hh-mm 6 Brief History of Present Illness / OB History 7. Physical Examination ( Pertinent Findings per System ) General Survey: Temperature1 Abdomen HEENT Chest/Lungs GU(IE ) Skin/Extremities CVS: NeuroExaminalion 8. Course in the Wards (attach additional sheets if necessary). 9 Perhnenl Laboratory and Diagnostic Findings ( CBC, Ufinalysis, Fecalysis, X-ray, Biopsy, etc ) 10 Disposition on Discharge: Q Improved\J Transferred\J HAMA\J Absconded Q Eipired
Page 1 and 2: Republic of the Philippines PHILIPP
Page 3: MCP[2 | iPhilHealth I Your Partner
Page 7 and 8: GUIDELINES ON THE PROPER ACCOMPLISH
Page 9 and 10: Part V - Consent to Access Patient
Page 11 and 12: Note Check the box provided if offi
Page 13: theictusonthefirstminute-andfive(5)

li1 - Philippine Health Insurance Corporation

Create successful ePaper yourself

Delete template?

Save as template?