A0Yfe'"'3^| - Philippine Health Insurance Corporation

*~ ,Republic ill llw Philippines 

*~PHILIPPINE HEALTH INSURANCE CORPORATION 

*]. Beginning lanunry 1, 2()lj, all members availing of the Z Benefu shall be 

rec|uired a .V\ear lock-in membership pnor io availmeiif of ihe beiKfit. Ihe 

lock-in membership does nut; apply to lifetime members and sponsored 

program members; 

C. Pre-authorization from Philliealth based on the approved selections criteria 

per specific 7. condition shall be required prior to nvailment ot services. All 

requests tor pre-authori/.ation shall be completely accomplished by the 

i'*):*" MA. TESCSAA, OUIAOIfI: 

A0Yfe'"'3^| 

I Dala:i-pM.. 

i CESiTsr-ssD @]@;@!;?@!@: copy!

con fended liospiinl .nul submit u-J lo llic f k-.id i >[ ilic lvcî< >n:il I'jcik. N p; 

Atlniinisit-.iiK in St'Ci i< fii Me :ippvov,il < u- dis.ippeov:il; 

D. Thi^ diagnosis cinritio pi sli.ill b( nbi 

H. No balance billing (NRB) policy @diall be applied for eligible sponsored 

program members anil their tjiialificd dependents. Negotiated fixed co-pay 

shall be npplicd for eligible non-sponsored members ;md their uualified 

dependents. In n< instance shall [he fixed co-pay exceed the package rate; 

lv. J'Ik- professional fees for -uirgen of CUKt, TOb and \ SI) shall Lie 2H'\. of 

package rale; 

llie package rate; the ptolcssional fees for cervical cancel is 15" .1 of the 

G. Pn lien is enrn|]t ihe actual length of stay of the 

patient 111 die hospital. Such deductions shall be made on die current \ear and im 

deductions shall be made in the succeeding year. In crises where the remaininii 

annual benefit liniii is less than five i'5'j days, ihe member shall remain eligible 

to avail ol the Z Reneht, provided ih;\i premiums are updaied; 

11. Any complication,'s arising during the hospital confincmcnl for die ["'articular /, 

condition shall be pan of ihe package. 

I. Hospital conlincmcius due to other causes as determined by the primary 

condition shall be paid separately; 

). All rales aie inclusive of government taxes, 

K. Rules on pooling of piofe^sional fees for government facilities shall applv; 

I.. In cases when the patient expires anytime during ihe course ot iriaimeni or 

the patient is lost to follow up, the payment schedule toi die specific 

treatment phase shall still be released as lonu, ns the patR-nt has received ihe 

scheduled tieaiment. Ihe remainiini irauche sliall not be paid 

M All mandaioiT and other servicis of ihe specific Z conditions shall Ix- -ivcn 

according !@ > the appr. >ved clinical p-athwa_\s, trc.i linen i pj-oti >c> >ls, clinical 

guidelines and odier siandaids of care. 

III. CASE TYPE Z 

A. Elective Surgery for Standard Risk Coronary Artery Bypass Graft 

1. The package code is Z005 which includes die following 1CD-1M and RYS 

ICD10 

MANAGEMENT/PROCEDURES 

RVSCODES 

120 

US 

l'.i|.i-.AitfiiB>p;,ssGiaftSmi;,n 

33^-2 

2 The package r.iic shall be P55U, ODD for rlu- entuv coi 

3. Sck-ciions criiufin i\)\- ("AUG: 

a.Sj^hclI McmbLT 1 @',ni|T"iwci-mcnt 'MIî Iol'mi 

b.Aiiu 1^-7(1 vc\irs 

Ml

1 

i 

1 

1 

c.Stable (..nunnry Arlcry Oiscnsc ilûiiiii^ I-J.I'Cl'iX'l-1. ISC iJ.A'l I '.I > 

(ônmarv An( j) with indicai iwii 

hascd n e< nonary anatomy, symjiiom seventy, I A' lunnn >n, 

and/or vi-.ibilirv tests; non-invnsive lestmg ccMiipk-ted nnci 

discussed wilh piiticm 

d.(Ain-eiu Medic:il >tnLus 

i. Not m severe decompens-.ued he:irl f;iilnre (N\'1'C I\'j 

ii. Not with severe iingin.i d_X_"S i\ 

.lin,K 

n/

?. "J"he p;ivnu'nt for rln^ pneknye shnll be Five Hundred Fifty Thousand 

pesos (P550,000) fur the amipk-n: roui^t n\ onrc winch sh:ill l.n- îvl-ii in 

MODEOFPAYMENT 

two i 2) riTinches rv> fi 'Hows: 

AMOUNT 

FILINGSCHEDULE 

Wi.lw.iMJ.ivs.llnJisclm-;;,,I",,,,,,s,,,M,.n 

h.-mndyiKimir-p:ipu.-,upi-i:ilivrsin--v..niulr:irc, 

r.Milnin:ici..|iofendia.:n:]]aljilil.iu..iic>1'Drlia.:@,,t 

B. Surgery for Total Correction of Tetralogy of Failot 

1. The pack-,iL'.e code is Z006 which includes ihc fullouiii,. K;i")- 111 and RYS 

c, .des- 

ICD10 

MA.NAGEMENT/PROCEDURES 

CODES 

l.ii:iir.,u,-an.iic.lI'l-Piiil'ia;"tl;.illnl 

3Selections criteria for surgery for TOF- 

2"'1tj.inclK- 

3.v,'n,r,(."-l,.iV,n- 

2The package raic shall be P32U, (Jdn fur ihc entire course of treatm 

.1. Signed Membui I 'jnpowerment fMJ'"i Form 

b.Age 1 [o 10 venrs + 364 days 

c.21)] @'choenrdiogram . 

i. Pulnion.u-y ,iriei y size 

@Mc(.i')ii's iik!c\ lAorui/'I'.T i-.ilio > >_ 1.5 

@/, score Pulnionnrv \';ihx Annuliis : Accepi;i 

.scoi'e /HSA : >. -7) !- better 

@Z score penplier.il PA's : Acceptable if >_ 2 or b 

u. Absence of major aortopulmonary coJ lateral 

iMAPCAs) 

d.If cardiac enthctcn/alion / hemodynamic study available: PA 

adequate by /- score suinJards/ ]^SA 

e.No previous cardiac surgery (lil.ilock Tausîy Shunt") 

t". Functional (-hiss I -TI 

g. N1') c>-morbid factors, such as nny of the- ft: 

in. Pivoper:irupe seizures 

iv. Hraiti abscess 

v. Sti'oki.- t-venis 

vj. Rleedmg disorders 

vn. In tec live endociiixlitis 

vin. Other congenital anomalies 

CtUT 

!Itate: 

!__'' '' " 

iIJtAOU

4. The npprovcd clinicul p;ilh\v;iys tW IOI; chilli LX'llc-: 

uiln.T scivitx's us iiultciu-i-l in ilu- iaI.iIc W-\< >\v. 

MANDATORY SERVICES 

1Prt'-up l;lhs LUC |>1;iil-!ci ri'iml, N,i K C;l Mi;. F I 

2l'rc-npUI,mclni:mrt/Cl>cln,:,,Kt 

Hriu-i.ll :uicsi1r-si:i 

-I l\.sl-..p bl>s PI. PT1 

5Pulmu hlv A1UI pif-^p, \1U; I.k cii..- clLTtL.,l'.k-., 

OTHER SERVICES 

2. ( itlu-r ihclK as indicated, sue]] ,1-. 

@jcii cphaU'sponus and .njl 

> Puliunnjiv l:hi-, -aIk-ii ii.-t-Ji-H, s-i 

-I I Itln-r s]u-i-i:iliv sl-ivii.-c.-s .1:. hl-l-lIi-c 

6R,nlio[,^v ,;|n-.;l :.-|;H 

N"ii-lliv.isivi- ]:ihs. ;,@@. imUi, ;n,-l. 1( M1{l;., p..M up 

!@:, h.i-( ins. is-ii:ni i-.rt; 

I-;. I 111,IT lill,,. :|.i illdnMtrJ tllll v, BSS.1V 

:uiiil,.ir ini. m,rlnl|Mvil.m,,l.MU 

I" ( Jilar imxU a,. iiuIkju-cI J..p.Hiiiiic, J..lnii.iii.iiu-. 

I ! lll.juil @.iip|ii>ri--^-n-.;ninji & l,]..il piojncis 

12. Pt-di.i Can- Rfh:ihiliia[inn (4 muraii1] 

5. '1'hc payment for ilns package shall he Three Hundred and Twenty 

Thousand pesos (Php 320, 000) lor ihc complete course ot care whicli 

shall he fjiven in i\v. i (2) in'iuche^ a> follows: 

MODE OF PAYMENT 

Wirlun (>U J.ns :i fu 

FILING SCHEDULE 

Wiihin (il.t il:iv. .iflL-L- .zumplclmn ,,f 

Ktliiihiliiarion llxert-xsi- Scs.sii'n> (.V'l-4"1 

- tl< 

O Surycry for Closure of Ventricular Scplal Defect 

1. The puckniiL- code is Z007 which includes the fallowing ICL3-1O -,ind RVS 


RVS CODES 

ClnMiio "I" W-niLiLiilju Sl 11 tul D.-lVci with i.f wifhuiir 

2.The pi-ickiigc ral c shall be P25O, (UK) toi: the entiu: course ol irerunK-n i. 

3.Selcciions criienn f>>r siirot-t-y for YSD: 

a.SigncJ Manlx-r l-'.nipnwi mu'til (M !'.} I @'@ .rm 

b.Age 1 I'j ? VL-urs + 3G4 Jnys 

c 2r)-echoc:u-t-liooraplni 

i. iKolnrcd \SD pL'rinicmbr:\nnLis, sub-,u>itii: c>r Hubpulmonic 

ii No coniljincd shunts such :is ;iiL-i;il scpml detect or pnienr 

diicn.is nitcriosus or ntnovcnincuku" scpt:il dctcci

in. No miIkt assocuied Cl ID's . such us o -;ircuiin>n ol ihe ;ior.i;i, 

(ii; modeinie lo severe aortic i nsn 1 Iicu-iicn . or modern ic lo 

Slavic [nilnioinc ^tumsis 

iv. ]'uliiinn;irv ,incr\ pn.^sui'c: 1.5:1 

J. No piL-\-ioLis c;h-Ji:ic sur^cfy (PA Bniuling) 

c. l-'iiiicuoiaiil ("Ms* I -11 

f. No co-mnrbid factors, such as ;iny oMhc ft": 

i. Pr*. npc fnnvi.- seizures 

n. Brain ,il">sccss 

iii. Sirokc cvcnls 

iv P-k-cJintj, disorders 

v. InU-erive endocardiiis 

ij,. No chit)mosoni;il ;ibnoi"in;ilmes niul oihci" :is-.t x;i-,i i ftf a >nu.en n :il 

dclerl, 

-I 1 he ;i|ipL-o^cd clinic.il p-.nhwrt) s lof \ SD shall letled ilie mandiitoLV ,ind 

oilier S( i vices :\^ indioiled in ihc inltle ];>elow 

MANDATORY SERVICES 

i i..ii>. c:ii:.. |i U I @ I' 

l'lt-.,|i mnb ;inlil.i.,n.. |H.i[.lnla-.i- '>:-, v :in,-..in. nil. 

aiiiih;innl, nKTlivlpH'Jiiis.jl.iin- 

') ( UluT im-Js. a- imlio-.Mi'd. iLpjiniiir, ill .liurainiiii-, 

iinlriniMK, l"ui.it[imli- l\", .::iL-iiini KliK.,iia[r, iliîsm 

(..mil. I"m....niiKlr ..i.il, il.,i,.i..r,.n,,..i[>i,,]iril 

in 1 "j! (.: n. I Mi|.|i.,t-[--@... u-cniiii; anil lilno,] .nhIik @!@. 

1I. I'^lia < an- RchalulitaiH.il ( I ,r.:.nni-a 

( ,iIk-. 


l>..-:l..pi-i-.m\i- :iiiMl.ion.:s .1, nuliiai.-.l 

liilli:ivini.|i>. :iiul . >r;i]l 

I UliLT MU-ils. ,r: Ilnbc:iH''!, -.ii.-Ii .1:.

hl.ii 

C Cervical C;mccr CluMTioradiatioii with Cobull ur Primary Suri^cn 

1CD10 

he puckn.LX. code is ZOOS which includes ihc lullmvniii ICD-10 ,,nj R\'S 

odes- 


RVSCODES 

lYIvnCl.ali 

Rr.icllylhi'iiipy[l.nvil..-.risuT.iMI.-i-.lili.il"i 

@.,(>-ln;s 

@4lil 

Kaihi.ili\s[,avu..niYi'-ilhhil.iu-L.i]prku 

IvM.pha.kiii-M.in.v:im,Ip:l.:i:,..nifhmpllMi.ik:,i,iipllMU 

@-@-111...,"V.-illl),bn-nls,,lpiiif;,,,,ph.,nTluim 

58211, 

2 11k- package rale shall be P I 2", ()

l. 

1 

O. Cervical Cancer Chemoradialioii with Lineal Accelerator 

1. 'J'he p.ickiif-f code is Z00 which includes the follmvine IC1)-I(I :inil R\'S 

codes: 

ICD10 


Ilismpniholnsj 

RVSCODES 

i.hir 

Chcmollicr.ipy 

Rndiollicr.ipv 

1iiK-:ir\c._fK-iMIitt pii.o-.iiiuj 


( Jllici IHCi.K :l @ IIKln.lU'tl- 

;in.il-(.M..-', 

imlic:ni-Ll (imi:;r.-fii

,1'hpi 

4*.. 

4 

Republic of the PUUipfincs 

PHILIPPINE HEALTH INSURANCE CORPORATION 

( @||\M;ik-( Vniic Huikliiii: 7(i) Slum U(iulc\ ;nd. I\imlj fi[\ 

PRE-AUTIIORIZAI ION REQUEST 

STANDARD RISK ELECTIVE CORONARY ARTERY BYPASS GRAFT SURGERY 

o.vrr. ofrhquks'j: 

I \m> is I- t Let] nest ;ippi (>' 

f ^tvicus uirIlt iIn.- /. bi'iK'tii p;icl.ii^f I 

K '< (MI'I.IVI T. NAMI . (!@' 1\\ I II 'N I'liNAMI @'. ( >!@ I K ISPI'I \ I.-, 

'] Ik- p.uk-iii 1h-Ii'Ii;;s d> llic hill. ,.\ii iu cnuûv flick ;ippi opi i;il.. I 

D NBB 

l!ri|iKSH-d I 

I'imicd Name lv. Sii.MianiK- 

Anciulini; Cmlioh 'sîst 

I 'rimed N;inn. & Silmi.u 

.r 1 )itvcior/( :iiu-r@- Pliillu-.ihli I'si-Onlf. 

?APPROVED 

?DISAPPROVED 

(Siiiiuuia- o\ lt Printed Ninncj 

c;kI. Ikncfit^ Atlniini^ti-iiiion Seen 

TÂLTH -j 

I SS''*1 MA. ITiirSAA. QUIAOIl S

k. 


Republic of the Philippines 

IlLTilllilinc-l-l l-"-t-l-l www |i!iiihc,illli Lie\ pli 

PRE-AUTHOKI7.ATION CHECKLIST 

STANDARD RISK ELECTIVE CORONARY ARTERY BYPASS GRAl-T SURGERY 

P1:ict ,1 'arN \i 

\lk-in.liiifMl) 

In1 

1nil 

wiih(!AIK>(.lin-iny,ihi-iikIihiîoii 

d(MlC 

-1(:iu'd

1 

1 

'k., Republic of the Philippines 


Ciiyr.lo 

a[or\ 

lesls 

@ 

@ 

''-';- 

@ 

@ 

c..ii 

1@[is 

[um 

@ 

HI 

\ 

@ 

(jx 

@ 

Ch 

-siXRav 

(T 

ral, 

@ 

12- 

J'.AI)1 

@ 

@ 

@ 

Bi, 

Ti-i 

I'la 

.in-aii\ 

@maUim> 

',< 

nl 

,pl,,S 

illHint; 

Name&Siu 

Caidlol, 

lain 

1LMS1 

eof 

II.Mi 

@ 

@ 

@ 

Jim 

Bil 

Sia 

Al 

ions 

lffl"d,er 

in 

I-1.inhilMl 

"@ 

,rAR 

1! 

@ 

@ 

IV 

iperam1 

plnlasis 

\ 

Name&Slji 

lal11 

iîsi 

eof 

7T7hi. 



nLy.l:i!e Ccnlry r.uiMinc, 709 Mmw Boulevard. P.r,ir_ Cilv 

H^lllilini? s(( 

;il Siiiv,ic:i! It!! @ 

Ancsihi'siulpîM 

( .(Mil IIH 1111^ l'i >s[(i|X'l ;UlVr ( ; 

;ll R t f_i 111:1 r n n nil 

I. Cill-lll.R Kdl.lI'llll.Kinn 

'.;uJj..|'.[MSl 

Authorized C.inline Reh.i 

Si,iff 


OHiliimedih.nc by 

C-.iKlinloijist /Unlcsign 

I .Nil.liin'inl l.ilc.i.iu.i'- KM-; .1- m ,-il. 

i l; ( T'< . I'l.in-K i '.-MiiLir. \[> I I , 

I1 I P \ I,". !?. I'llS, i\.i. I-.. Ml-, 

\iM1mmiuI ("111-.I '. ki\ 

2\ J T " I ), I 1 .[ '. .1- IIKllU.m ll 

.\nll, I.i.ii-Iii.i] inili-v i.:i.,.h,l .Hi|.|,-\ 

ll\ .11...I) 

Iu-|'.iiiii. I M II. l..n.l..|>.ii- 

.,11,-h .is I.i-i:i .iu"in~t I -in, 

CABG MANDATORY & OTHER SERVICES AND TRANCHE PAYMENT 

jJSealth ~] 2 I 

CER 

a. iE;-:zs/\,\faui.\c!iT 

^

11 



le^llhliin? 44 1-744-1 

liiiLormnlf IV -.y 

,K.1,'.-,TI,.;,I. 

cc iNhoRMi; in imtiknt: 

I'nnk'd NnniL- ;iuJ Sigiiniuii- 

I1 

^ 

CAM". MANDATORY & OTHER SERVICES AND TRANCHE PAMMENT 

3 |

inh: 

w. 

Republic o/ the Philippines 


MiMllhliiK-.Ml 7J4.1 ^y/j.!]i]ILf_,iJihflt':._.l_:h 

STANDARD RISK ELECTIVE 

CORONARY ARTERY BYPASS GRAFT SURGERY (CABG) 

N:imc: 

Addles 

Ahl: Sex Phlllk-iillh N... _ 

DvlK- olWdnussiun: 

n.iu- of Disrliiiivi:: _ 

@K.\Ni .1 ii-. i ri:.(.)i 'ikkmln rs \ Service^ (,'lircklisi 

Accomphslu-J An,K-siliL'Si:i lu'pnri 

'@'@>. Disch.u-!^1 SumiiLMA Si-j.i-n.-tl In \nuulniij; rU\m> 

I XVI I '. ' '< iMI'l.l-.Tkl) : 

l).\ IT l'll.r.13 : 

A [ kiuliML1, I 'h\ sician 

IVink-d N.niK- (S; Si^nuiuiv 

Accniiw r)n-fcii>i-/iMct.lic;il Cliiut < 

(.()i\;] < )k,\ir. i\\ i',\ ni;.N i @. 

l'nnlcil Nnmi.- .in MliNT

Uinli 

** *Republic of the Philippines 

wPHILIPPINE HEALTH INSURANCE CORPORATION 

^Cilyr.lriie Centre Buikliiii-;. 709 >h;iw Eoulâid Pasig Cily 

ftfMKilthlme W1-7--UVI wwwjiMhL'alilL[lov.ph 

STANDARD RISK ELECTIVE 

CORONARY ARTERY BYPASS GRAFT SURGERY (CABG) 

N.II1K 

Ukln 

\,y. Srhill k-nllh N< i 

j'I\.\nmpli-tcd Tcrrificm1 of < M'l) I 'nlluw-up a>n-;iil[,ui"n 

11\7TTi'jn;ii 

w^V 

@r-LM: 

! CE--;3| 

ft !V 

CABG MANDATORY & OTHEU SERVICES ANDTUANCHE PAYMENT

ItLimblk nl ilia Philippine 


' ri*'.i;i[L- ( liiIk Kinking 7n';'.h.!,, nouk-v.iMl I'.iml: i.'iI\ 

PRE-AUTHORIZATION REQl'EST 

TETRy\LOG^ OF FAl.LOT SURGERY 

d,\tkoi; kr.gur.si: 

hi'- is I') ivijiii.'si :ippruv;il Iw prevision f servici.-^ hikIci' ihc /' Ik 

(COMri.Ki k nami: < >i- iwi ii-;nti(N.\mk < >\-11< >sjjil a i . 

iiilIi.-i- lliL' iL-rnr-. :iik1 C"n>liM(in- ;)@- .iL'.tx-cd (@ -\: ,iv;iilincii [ ..filn- /. l^jict'it l'lurkiif.a- 

Primed Name & Signal urc 

.NriuiJinjj PeJliiinc ( imlu .Imîm /' Ol'l ) .- Mi--iih-.ii 

S( H.I.M. S1.K\'|i;i-: ASSI .SSMI .N I 

'I lu |">;ilicn[ belongs m tin.- t< >ll\\ mil1, ailc*.;1 >i\ 

Asm^cJ I 

(.( INFlRMkn PA 

IVinkd N:ini rd\ 

M( ) ]"I @ 1 > B\: 

l;\r / Chief ' 

rlor PhilhcnllliUse ( >nl\". 

n ms.\riji >vi-:n 

[SiLMiiiliiix- over 1'nnlL-J Nnmcl!' * ;.^X -;T^@;@@^--2-__ . 

I k-;nl, l^ciK-tlis AJniinisrr.ilinn SuciumS ''^.a !@@- T-^T-rkit^/;'-^ |; 

:fS: 

35^fp^r~i

i. 

'.1 


i n 1,1 lilies i >r i iilu.'r c 'iiucnir.i] drkrr^ 

D 

i3i,\ciN( isi k:s 

\ru-.icd !)@, 

Murk 2\) i;chnc;n\lioLM-.im(- 

:i Willy Wnincuhli Scpl.l] 1 XlrCl ;iiiil 

Piilincnic Stenosis, nKulcr.ik- in st-vciv 

h No ollu-i ;issoci:iti.ilm. line \-;il\-c; .\rnn\ i.iitricul.n- 

St.-pial Ddul (AN'SD) 

(.@ AtlL'tjiiiih.- pulinon;uv aiury si/ ri ..sli.is 

w 

W) 

/r

Hu-Ili: 

c w. Republic of the Philippines 


TETRALOGY OF FALLOT - ELECTIVE TOF REPAIR 

N. 

\< 

inK1: 

kllTsf 

\jy Srx Phill k'illlli N< 

Ii 

1); 

1111III" 

iii...r 

\, Imissi,, 

i)i sdi,if.;i 

ii 

I !;.\N(.I II I lU-.i^l'IRI MI.N 1'S ( I ir.i'.h.l.lS I 

1. liisl Tiunchc Payment 

riciM i : 

!. i:..|n ut(j .mulcted Ml'. NORM 

@ ''-o|n ofAjipioyi-iJ 1'iv ~.\iilhori/.:ilion i_ luckhsl tt K.:.|i k-ii 

i. < '.onllrm.U'ii @. I 'K-opci .11 ivi- I .ill icuk.i V I-a-.mus 2r.)rrho 

I (;niplcU' Nip.noil < ij-kt,i[iw Rqi'iM 

1 (.(MliplulU ,\ll;K-S[lH->i.l l\f|V.l| 

f'. 1 [111 ;lwpi_-i;il!\ f I];. I . Rep' H I,' I i imslhoi :irlr \M[] nn ?ilI,i\'S post p ;. \ I l;n. li K(.-s 

~. MAN11ATI >RY @ 

(a >ni-( ji;mim 

Rf.huinn in ]';iiu 

I1! mi i.'d N,n nt. .nit 1 Sii^nin 

l.WllllK'lil* Rlvic'ALxl b\ 

I'l in.i ir.Ai.i 11 /,'m \nac;i-:u 

IVinud N.imc & SiL',nriHii\ l'nnicil Nairn- ls: N.'j.m.ihmt 

l;AL-cumc niuruiiyMcdioil denier Cliu-t" 

l,.- "#r:^ |

,irth: 

w. 



Oly-.l,ile Outre BuiMin^ 709 Sliii-.v Boulipvflrd, Pasig City 

Hedlllihri- 4-U-"'-J-1'1 t\^w |ihilliPLHlili no; |>h 

TETRALOGY OF FALLOT - ELECTIVE TOP REPAIR 

N hi lie: _ 

Alv:Sex I'hill L-iilil, N.i 

D.nc of Atlml'si, 

@i:.\ni 

.NTS i I III KI.IS1 

1. Second Tranche Pay mum rli.-:i-i-dl,-i 

I I :..mplcicd I'l k.- lV,.li:m-ic 1.;u-Ji-,k- RJi.ih l-.,,-ni -.will -I w 

-L_l\''i!JKiLl_Eli'!ii]!i.lllt_L'l'i 'pl) ^'""^'1':"'"" 

3 PosiLpiTnlivL1 21V-cho ivsull .nmchuil 

Tr\~nTrn lo 1 'illic ni: _ 

I )ul-uiik'1iIs Reviewed l.iv: 

I'rinirJ N;im

w 



HiViUhhrv: .1-11-7.1--I4 

O:iil Dlsclun-^.d. 

lie . Uimil icu 

rliill Icallh ID Number 

TETRALOGY OF FALLO T - ELECTIVE TOP REPAIR 

CHECKLIST OF MANDATORY :nul OTHER SERVICES 

TRANCHE I 

i PLicc :i ^ -.iiul (ii'lie.ilc sl;ilu:- ui- J,iIl- Join, or |L-i\ fuj 

SEUVICliS riKS'I"I KANCHT. 

Clu-di :liul l.ulic.M 

D.iu- Done/ C.iici 

Aitcsucl by 

lNamt& Sinalu,c-"l Aiu-nilmi: 

PllV'iioilll) 

:l I 1 v. nil |'.l:ilcl. I ullh lili 

(I I :n-i 

I.' I'll.H 

ii.iI :,.,:!,: 

.1 \:iil'...| 

1. \imU< 

K, pI 'I rn-.il. @-'



Hesllliline 'l-ll-'/M-Ti v/ww pinlhonllh iipv 

4\h.k..lhr;,i:i i ( 

( ],,vl. ll ;l|.|.lu-.lhl, ;iml 

plan Si.iiu. din "i iinln" 

1.I ,nuir.l 

i-Mi.l.iv.'.liiii 

>l\M-..pi,,-- 

-I V>;.iiik'|]i 

II'@ -iiiiii 

INrp.,,,,, 

,11 ...p:,.,,.,,. 

I n.l.i ii-mii: 

,..N.u.yKcr 

@ IMil, ,,.,,@ 

i4KI,.,ii,:. p.,|, (\ll:..li 

jn>l|..:ll,l,') 

? IA\ l> ? !>RH' 

.1 cni:-.\iiii|ii.iijM 

h

icihcs H. 

L, 



9. Postoperative Medication1 

a.Dopamme 

b.Dohutarnine 

c.Nitroclycet me drip 

d fviilrinoiip 

e Calcium Gluconnte 

f Tramadol 

g. Midazolam (sedation) 

h RanitiJine 

i Oml Digoxin 

j Oral rurosemidc 

I; Oral CapLopril 

I. Oral Paracelamol or 

Ibuprofen 

Check if applicable and 

place Status/date or NA 

L. _ 

M._ 

(,C)NI-( >RMK- 

. iil/lru,;il t 11 i,i]xl];m "I P;i 

H.-il M:iiik' :mtl Siiî 1,1111re 

Kd;lliii Id P;lllClll 

Documi-ills Hr 

Pruned Nnmc &@ Siynniuic 

im 111,1 ii;..\i;ri i /. man \c;i:k 

AllL-.Ird hv. 

N-.ink1 ;iiul SiL'.iirit liil1 of A [tending I'lnsiu-.m 

NiiniL' iiikI Si^nniLiii; ol l\\ecuii\ c Diu-cir 

Mcdw.Ml (.CI1H.T Chief 

TETHALOG1 OI FALLOT TRANCHE I 

U^wZ\ 

i . @-@ "r. V~:i^^f.'7!i!jiAf51~ j

w. 

KcpiiMh- n/ ilic riiilii'i'iiifi 


(;i|\'.l;ilc < ciiIil- I iuililiilLJ 7()'i Sh;iu Hi>iili'\ ;ml. IVisili ( i|\ 

PRii-ALi'J'ilORIZA'J'ION RliQUKS'l1 

VENTRICULAR SEPTAL DEFECT (VSD) CLOSURE 

r>.vn;. (ii; ri :li-d l)\: 

1'nnln.l N.iiiir Cv Nlmuhuiv 

\m i Klin- IVi.lininc. t ;.n , IioIm-im, (MM) ( i.niMilliu 

SOi.lAL SKKVICK ASSI .SSM] .N I 

I he |i:hk 11 

? nhp> 

> l\w IoILauiil' c.iK-l'.ha: 

D 11X11 ) i.

\-is,s


Ili'/mliln- nflliu I'liilinuim 

I icillllhlK- 44 |-"-l-l IUUU plllljlL-Elllll ! 

Ull< 

I'hill lejlih 11) NiiniU-i- 

PRE-AU'J 1IOKIZA1 ION CHECKLIST 

VENTRICULAR SEJ'TAL DEFECT (VSD) CLOSURE 

IJI.'.\1.IN 

Ml 

\l 

II 

"@' 

Annr.NO 

cihsuITr- 

rn.il|,,,.-, 

.1mode- 

Kblood 

Humuu-(l' 

ICM11- 

!:ll 

eh-.1^ 

k-|:il 

loSh 

i.-:i>l 

? 

? 

? 

? 

,\l Irnsl 

within d 

Cllixlinloai;, 

ihidi < H !H l.\[. 3D I-.CI ]( i KKSH/IS 

@ @@' i,':\.'u\:i.fn'f\'ci!iwff~ 

K:

^ fRepublic of the Philippines 

*"PHILIPPINE HEALTH INSURANCE CORPORATION 

J\C H/'Lilf ("cutu" L'-iiiliiin;;, 7rj'J Sh.v.v Donlv.ircl Pas if. City 

^llpjUlliliii'-- .'MJ-7.14J 'awa nlnllitMlLli (;\ ol CoinplfU-d Mi: I @( )KM 

2( j >pv ol' Appn>\ ,_@( Pn. - Authoi i/;iii. in ( 'hiA-klisl ^l\t^|nc^t 

i I :..nHi in:ilci \ i^vo|,L'i,im_c l.:iboi-;u..rv I-A.iin- 2Pivln> 

-I. lîniiik-u- SiiriyaiU lpi-i-.iu\ l- lU-pori 

t. (.umiTk'k' Anncsl lu-si.i IU poi I 

f) hlll,M>|K-|.lllVC I I .1 '. I\L-p- Ml/' I I ;lll.-llli i|-;k;ic \V"M 11111 .1(1,1^ po.q (.[, ^. \ I I; 11/ J1 IUsi.lI 

7 MAN!) A T< >\l\ Cl II @.C|.;| .IS'I ( >!@ S7 R\'I( :i S SI( )N! ^l_l___ ~" 

S i:i,INI':AI, .USSTR \'^l_ Sif.M.i-11 \_ \_l_ll-iiLliiijî'h~,"iicinn~_~_"' 

9. ( jMnplflttl '/ S;in.sl;i(.Ii'>n tîicslli tnnairc Signed 

In. vST7p7\ r.uVASK kn"("x"i'iJ)i:.i:j"' ""' '"'"" 

I I Cumpk-kxl nml sl;;nl I'luiiu-ilih

-th: 

1. 

Republic of Hie Philippines 


Citysl-Hf Cfime Building. 709 5h;nv Boulevaid, Pavt1. City 

He.illlilirK? .l'U-74'l-l ,vw,v.pliil>Vf.ilUi.PLOv.pli 

VKISTI RICUI.AR M-TIWI. DI'.I'K.T - KJ.FC I I\T. VSU (:j .(J.SL'KI : 

N:iiik- _ 

Aikl.vs* 

\;m." Sc\ I'l.lll k.ihh Ni: 

11;IU' ..I AJlllis: 

D.I It ofUlscIl,! 

TK.\N( I II' 2 RI-ul/IRI-.MI-.N I S CI II .1 kl.iST 

II. Second Tiiinche Pay me nl 

1I :.iii)|)!l1cJ I'l 1C- I'l.Ji.ililc: ( .ii\li;ii.- K.-luih l-ui-in '.Mill -I @i^si.m., 

2[\ktln:;il crninc;ii..' nl { )\'l) .:, nisiill:i[ion 

i)A'fF~n>Mi'i.r.Ti;i>: ~ 

i) \ n: in.r.n @. 

< A ihrORMI.: 

IVinU'd N;inn. :iik1 SliiN.Minx' 

Docinm-nrs Rcvk'avi 

I'niiu-d N;iiiu- & SiniiuHiiv 

I1! 111.I II- \].1I i /. M \N \c: I-.K 

AlkSk'll 1 

Pruned Nbiim; ;ind Sh. 

A I U@ iu 1111ij Physician 

Primed N-niK- .ind SiLnmturi1 

I :\L-aiiivc Diifcmr/Mctlicil (I'niu- Clik-f 

fcl_l 

'% 

ji: w>

iuLkt 



OlyslJHfc feiHr'H GuiMiiig 709 SImw UculevJuri. Fs.iip, Cily 

He.ilihline 4-IJ.-7-1--14 w^.w plullie-alUi r.ov.t'l' 

_Dliu.- AdniilLccl @. _ 

Dak- Dlsrhnivcd: 

VENTRICULAR SERIAL DEFECT 

CHECKLIST OF MANDATORY and OTHER SERVICES 

TRANCHE I 

llC.Hi' .-I ,ll H-: i >l" I );lli.- d< )lli. 

SERVICES FIRST 

TRANCHE 

Aiccsled by: 

(Name & SignaUnc ol Attending 

Pliysiciiin) 

lVupr;ui\ r ] ..iIjml-;iioi n 

.1. CM', willi plnltlu-l willi 

HUkI npiiiij, 

Ij.CIk-si N-i:i\' 

r 1'ioliniL 

T. !':nli.il I lii.,inh..|,l.isnii 

:i Yiiiicnuai, 

Ij \ililk:lClll 

1'nx.v.iiiiL- ilom- . I'.)31 

1Yd 

\'Si 

\ M ) l':ildi fiosinv 

:\ \lK--. 

Ihe'ii 

li.iC: lull.i' 

VENTRICULAR SEI'TAL. DEFECT TRANCHE I

. 

i~. 

c 

fe 



nlihlme -1-11-74/11 ^wiv uliillienlth rcj ph 

C\AlK.-llR!.il)loSIM. 

:i.Scvoll,,r,iiK- 

I)K-iirnnvl 

eMidiizohm 

1,\ 

IIC. 

iSodiumbicnb.Mian 

j.Pnhi!..,iinnCIiIdi-kIi- 

kMiimu'-iiiiniSultvui- 

1.1lc]i:ii'in 

inlîolamincsulplmlt: 

.i-:. 

:r. 

I;1 

11 

p.NiM'o^l\-cfniif 

 

\'l-||Ii1;1I.h'\'Siippiui;ifIl-.isI0 

Inni1j- 

! 

VENTRICULAR SEPTAL DEFECT TRANCHE I 

I'Pj'lVj-.T/.U'ii[ 

I-::3|rn



tilthlme 4J1-7444 

A'w.phithrp.-iUh.ôv phi 

I'ostopcuitivc I .nbornlorv: 

S. 1. 1st 6 Hums pusiop 

;i. CBC wiili plntdL-i 

b. Clicsl Xniy (]M.iiT;iblc) 

d 

f. 

il 

h 

9. Postoperative Medications 

a.Dopamme 

b.Dobutamine 

c. Nitroglycerine drip 

d.Milrinone 

e.Calcium Gluconate 

f. Tiamadol 

g.MidazoIain (sedalion) 

h.Ranitidine 

i. Oral Digoxin 

j. Oral Finosemide 

k. Oral Captopfil 

I. Oral Paracetamol or 

Ibuprof en 

N:l,1-;,C;i 

)Sl(.)p.Slli-^llitl;i\'[1'ic- 

':iu-slXi.ivil1M.I 

n B 

li i':. 

I 

LI 

Check if applicable and 

place Stntus/date or NA 

1. 

\- 

\ 

r i A.__ 

c. _ 

D. _ 

E._ 

F._ 

G. _ 

H._ 

I. __ 

J. _ 

K. _ 

L. _ 

( ONH.iRMK : 

P:ii"cnl/I,C;iI (iunrdian ot Valient 

Printed Name and Si^naimc 

Dncunicnls Reviewed bv: 

Printed Njinic & Signnriuc 

l'llll.lJKAl.Ti I /. MANACIKU 

Allcslcil Ijv: 

Name iiiul Sigmmirc of A ncndinij, PhysicianN.imc nnJ Siunntiiru uf 1 '.xc(;u(i\f 1 ^nxclci-/ 

Mudicnl ( Center

1'hilllKillh ID Numhclirlh 


lU-imhlic ,iflhe PliM/i/iiucs 

i UllillirallliLir, |,h" 

PRE-AUTHORIZATION CHECKLIST 

CERVICAL CANCER 

'JUAI.II-ICATK >NS 

L fcipjuv 

(1'hcc ;i M'i 

Allrslftl l.iy Alluni.hivj, ( lyiu- < )na> 

."> No |nwioiis L-huLin)[hui-;ip\ 

< >no>l(>!jjsr 

3. No uiicmiirollcc.1 i;o-ninrbicl 

cmuljiinns 

IK;L.ir- 

cll!2 

MlltrfIIAI 

Sl.igeIIA2 

Sta.êlilt 

.Sl:i,m-IIIA 

Sl.lêIlll'. 

@-- 

t$Ui.@ i 

@@

^*" *Republic of lliv Philippines 

>PHILIPPINE HEALTH INSURANCE CORPORATION 

^1\)') Slum R(hi1u\;ih.1 IVisiaCitv 

W^1 k-Nllhliik- 4 11 -744-1 l\u.lili[IIU--iiJjll!;i |)[i 

PRE-AUTHORJZAT1ON REQUEST FOR CERVICAL CANCER 

1 his is lo request itppioe-.il lor provision o[ serviecs under the /. benehl p;ick:ige 

(COMPLK1T. NAMh'. Ol; PATRONI'I)rN.NMK ())@ I IOSPITA]/) 

under ihe Icnns and conditions as aî/ced tot :urailincnL ok [he Z Benetic Package for ccn'icnl 

caiKX'i. 

1 hi- palli'Mt belongs t'J the I".,M.>\vmim c.iKlm.i\ , ncrk \' ,i| .|.i:>i| -.rum- liox). 

TINBH 

D FIXED CO-PAY idic-mo, brach\ low dose, o.ljnll 01 |H-im.u-) surj'cn) 

U FIXED CO-PAY fdicnK., br-.icliy hi;;li dose & linc.ir -.iccdoi-.ilor) 

Rct|ucslcd by:NofL-d b\: 

Printed Name & SignaturePrinted Name & Sigmilute 

Attending Gynecologic OncologistMedical Director/Chief of Hospital 

rl-or I'Inlllc.illh Use Onlvl 

U Approved 

? Disapproved 

Head, Benefits Administration Section 

(Si'î"Kitur

. nr 

k 


Ki'imhlic njllic Phili/ipiiid* 

Ik'.ilthliiK.' -l-M-7444 JLJll!i!lKLiJilLi;! Jill 

N:uiil' of l-lospilal. 

_I)aic Dischiii-ged: _ 

Hiill-Iraltli 111 NumlxT 


SURGERY FOR CERVICAL CANCER STAGE IA1 - II AI 

TRANCHE 1 

(IM:h-c ;i ^ ;iiul uullailc suitus @ >r thin- tl'Mic (11 \i\\ en) 

SERVICES Is1 Tranche 

Surgery for Cervical CA 

Stage IA1-I1A1 

Check and Indicate 

Date Done/ Given 

Physician's 

Name and 

Signature 

Confoinic 

(patient's 

sign a line) 

I. PivopcniHvc ] ,;il>c irat< >r\ ' 

n. (;iu; 

bPhitclcr count 

c.lilood I'yping 

d.(^hcst \-r:iy 

c.)LCG 

f. 1;BS 

i. Nil, K, Cl,Cn 

h. (-LL'iiiminci 

i. AST/AIT 

|. Pi-o-timc 

k. I'nrLial Th]-omb(j]il;i^tin 

Tinu1 

1. I !rmniysis 

m. Ilistopmln>lo^\ 

n._ 

n. i. i\--L'T/ 

n.2. C.TSciin or M]U 

o. lild support, 

screening, processing 

ft. Cystciscopy 

(/. Proctosigmoidoscopy 

Dp, 

? q- 

Pi.copcrniivc antibiotic 

j?,.LTN ! 

Pr

c ^ 

k 



Cit>sUiie l.'unlio Huikliii;!. 70(J Sluw Uoulcvnnl. l;isiu Cil> 

I kMllliliiiL- 4-11-7 1-1 I \\\\u iiliilliLMkli.ui-i ph 

SERVICES 1SI Tranche 

Surgery for Cen iciil CA 

1 Stage IA1-IIA1 


Date Done/ Given 

Physician's 

Name and 

Signature 

Conforme 

(patient's 

signature) 

I'roct'durc done 

For Stage IA1 alone: 

1 :Airnl;iscial/Ti >ta 1 

Hysrcrccromy with or 

DniL1 of Procedure : 

("iynceologic 

Oncolugisf : 

w H lu ml bil-.ik-ml 

s;ilpinm>(11ill( Much>mv 

For stage 1A2-1B1: 

K;tdic;il 1 lyslcrcclomy wilh 

l.iihucral pelvic 

lymphndL'iicctomv, ]Tdc âmplinir 

? lUlnrcnil 

sulping"ph( ucciomy 

| 1 UanspoMtlon of f>\ ruics 

4. IMouti Transfusion Supp'Hi 

(it inclicalcd) 

niAVB ? prbc dm-p 

? 

5. Postopcnmve Laboratory : 

(.'heck if applicable and 

(when indicated, if done) 

place date >r NA 

@,i. ('AMI with phiiclcr 

b.i;r;c; 

c.clcLirohrcs 

ism Til live McJicliUi 

(as indicated, when needed; 

Check il" applicable and 

plncc Shitus/date or NA 

:i. Analgesics 

b.A nribiotics 

c.HtMnntinic* 

f:1 

Completed and Signed / 

n. 

Sndst:icr.ion Questionnaire 

C Jpei/ntivc Reeoul 

?- 

Attested by: 

Date:. 

Name and Signature of Medical Director 

n

nt 

liqmhlic of the Philippine*. 


CihMLiic ( eriiiv IliiiWniu. 1W Sh;iu llnuk-viiiJ. V,v.-\\i (.'il> 

HcMllliliiiL1 4-11-74-14 v^^.-lî'l'^'iillli.Lii^ |ih 

D;irc-: 

. D;Ue A dm ii led: _ 

_ Dale Discharged: 

l'liill-lcnlrh ID Number 


SURGERY FOR CERVICAL CANCER IA1 - II Al 

TRANCHE 2 

(Plan1 ;i ^ ;nld indicate st:iHh. 01 O;ilc clone oi- Ciivcn) 

Documents for 2'" Tranche 

Surgery for Cervical CA 

"Stage IAl-IIAl 

Please check ii 

applicable 

and indicate date 

Name & Signature 

of Gynecologic 

Oncologist 

Con forme 

(Signature of 

Patient) 

1. Mt'tlicul ( \-\ Mticnif of the 

oi_ii-p:ttknl foil' >\v Lip 

c< Kisiilhil ii m (w. itliin 2 

u(jcks posr-dp) wirh 

? - 

will ten i ctjiR'st h >i 

oulpiuic-nl p:.p mvic:,l-3 

mi >ntiis trcrn sui-gcry 

Hisropniholos^v Rcsulr 

(delniirivc surgery1) 

Attested by: 


Dale: 

\,!-;/.:WZ\ 

t"T inl',,,,,,!,;!!.,.,,!!!, ,.,@ nh

c 

Ki'/uiMii- til the /Vi;V:/;/i/i'.v 


fn>sl;ilc (. ciiiil' Iliiiklm^. 70() Slmu Houlu\-;ird. I';[mij Cil\ 

Daw 

On re Dl^ch:iiL>cd: 

1'hill k-:ilih ID Number. 


CHEMOTHERAPY, BRACHYTHERAPY (LOW DOSE) WITH COBALT 


TRANCHE I 

I'hicc n ^ iiikI iikIicmic sUIus . >r date dc.ilc .irKivcn) 

SERVICES1"TRANCHE 

(Chein*.),LowDoseBlachv, 

Cobalt) 

CheckandIndicate 

DaleDone/Given 

Physician'sName 

&Signature 

Confomit 

(Patient's 

Signature 

.1'rc 

:i. 

li 

c. 

cl. 

t1. 

f. 

.!;@ 

h. 

j 

h. 

1. 

m. 

ii. 

-jirocccUirc1.ubor:itoiv 

CW. 

PlntclcfcoLinlliloodt\pui^ 

i:cx; 

l'1'.S 

N:i,K.Cl,C;i 

(jcnrinlnc 

AST/ALT 

l'rolimc 

ParlKil1hroplaslin 

Time 

1nnnlvsks 

1lisropntholo^N' 

hnaiînir: 

n1.TV-UIV. 

n.2.Cl'ScnnorMRI 

liloodsupporl. 

nn. 

nc. 

ne. 

nr. 

nL, 

nh. 

ni. 

nh. 

ni. 

nm. 

n@. 

n,, 

H- 

//mv.-/, 

,11if,lorn 

fTZl

ers 

V Republic oj the Philippinei 


GlvsuilcU'Wrc llnikliiiji. 7U')Slum llinikvnr.l. I'lisip I iI> 

IknllhliiK- 14 I -741! nuu nliillirallli.iii'v.pli 

SERVICES r TRANCHE 

(Clicmo, Low Dose Biachy, 


Dale Done/ Given 

Physician's Name 

& Signature 

Cimfornic 

(Patient's 

Cobalt) 

Signature) 

2. Radiation Therapy 

( ivnccoloi>ic 

A. Pelvic Radiation 

? Pelvic Coball 

Dates of Pioccdure 

(start mm/dd/yy @ 

end mm/dd/yy): 

()nco]oi>isr 

Rikliaiion ( )nc. 

1^. l')inch\ riicinpy 

Dates of Procedures 

C i\ llL'L'l >1(hcr;ipy 

\;\\>t >r:itor\ cmiuis (. 

and cycle number 

I,H,lil,IV,V,VI 

(. i\ IK-CC 

Oncolo 

[. cue; 

(min/dd/yj.) 

2 CrcatiniiK1 

-I. Uiin;ilysis 

? 1- 

D2._ 

D3._ 

; if inJicrHcd ;iik! done 

D4._ 

15. ( .hcmolhcr^py 

Indicate cycle mimhcr 

Mcdicnrions 

?I- Ospliitm 

?2 t::irliopl:niii 

r,II,ni.IV,V,VI and 

date (mm/dd/yy) 

('.. Suppoi t mcclic;iijons 

QJ 1. And emetics 

Rnmosetron 

Indicate dates given 

and cycle number 

Ui,rii,iv,v,vi 

D 2. C-CSI-1 

n "'@ [lcmiilinics 

Ct1"L1I1ISCH"()11 

Mctoclopr;imi(.lc 

(mm/dd/yy) 

? 1- 

Q2, 

D3._ 

c 

Repnhlu- 11/ the I'ltilippina 


@ liilcf cnliv Unikiiny. 7WSh:n\ houk-wml. I'jsiyCi 

I k-iillliluiL @Ml-" I l-l û\\ pliillicallli y_u\ |ih 

SERVICESIs1TRANCHE 

(Cliemo,LowDost:Brachv, 

Cobalt) 

ClieckandIndicate 

DateDone/Given 


&Signature 

Confotnie 

(Patient's 

Signature) 

? 

ai\vij,Dpunrni-i']1 

5.Post(icatnicntMcJicntions 

(homemedications,if 

jndie:ilcil) 

Checkifapplicable 

andplaceStatus/dale 

a.Amiemetics 

b.\n;il(u,rsics 

c.1lematinics 

nc. 

(I.()i)k-i-s 

()i^wiiiplfidandSigned/. 

SahslaelionOnesIionn:ilie 

".Riulialion1realmenl 

Sumnr,irv 

A.Pehii:Radmiioii(cobah) 

11.Hiaelutherapy(1w 

dose) 

na. 

nb. 

K:idl;lll'm 

()nco]oîs(: 

i1^.(Jiem

k 

Rfpuhlif til (he Philippine 


l.'ihsiMk (.Vntiv [(inkling. ""I)') Slum lkuik-v;ii\l. ]'^\_|ilii!!iL-.i.l!!i llo\ yh 

N;unc of ]]ospiLal_ 

Dale Admitted: __ 

_D;itc Discharged: _ 

I'hill k:illh ID Numbci . 


CHEMOTHERAPY, BRACHYTHERAPY (LOW DOSE) WITH COBALT 


TRANCHE 2 

(Tlacc n ^ :iir1 inJ]e;i1c slaUis or \~):\\u tlont1 01 t ii\ en) 

DOCUMENT 2' 

TRANCHE 

1. Medical CcrtihcnLc of 

(.Hil-I'micnr I'ollow up 

( ionsultniion 

( Within 2 weehs posf- 

JNi- 

Please check if 

applicable 


? _ 

Niinic & 

Signature of 

Gynecologic 

Oncologist 

Conformc 

(PillilMll's 

Sigmiiiirc) 

pioccduic) with written 

lxi-jutsr lor out-purientp:ip 

snicnr 3 monihs posrpi:< 

ictdurc 

Attested by: 


Date: 

K 

@?- 

e:n i,,i,,..,,,i,inH

c. 

Republic ('/ llic Philippines 


CilWuk-

c 



Ciiwaie Cuilrc lluikliiiii. 70" !sh;iw Muulcm!. I'nîj: Cil\ 

SERVICES1stTRANCHE 

(Chcmorad+Linear 

Accelerator) 




&Signature 

Conforme 

(Patient's 

Signature) 

2.RadiationThcrapv 

1.PelvicRadiation 

QLinearAeecleiator 

startmm/dd/yy-end 

mm/ild/yy): 

Gvnccoiouje 

()nculogisi 

2.l>i;:icli\lluTapv 

1|}-li^hcloser.itc 

_ 

Radintion()ncloe,isl 

DatesofProcedures 

min/dd/w 

(.ivnecnloLfic 

Oncologist 

RatiiaiionOnajloîî 

(ivnccolotfic 

CtncoloiMî 

2.CR'nliniiic 

3-Mg 

-1.1rinahsis 

ni. 

n2. 

n4. 

IVCJhcmotliL'inpv 

Mcdiciitinns 

?1Osphilin 

i|2.Carboplarin 

f~~|3.Olhcrs 

Indicatecyclenumber 

I,II,III,IV,V,VIand 

date(nini/dd/^) 

P~l3.Hemaliuics 

?4.(>fhcrs 

1whenindicated 

nj." 

n2. 

n3. 

n4. 

r*i 

o

*-, 

'i 

Kvpuhlk- of ffie riiilippmes 


OlWuk1 (.Vnlrc Ituikluiij. 709 S]i;i\\ IJonlcwiul. I'.isiLL C H\ 

SERVICES1stTRANCHE 

(ChemoiatI+Linear 

Accelerator) 




&Signature 

Confonnc 

(Patient's 

Signature) 

4.\\ 

n 

diavudprik:ni-j-p 

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CHEMOTHERAPY, HIGH DOSE BRACHYTHERAPY WITH LINEAR 

ACCELERATOR FOR CERVICAL CANCER 

TRANCHE 2 

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Name & 

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