JULLIENNE LYING-IN AND

MATERNITY CLINIC
Block 36 Lot 9 Zone 11 AFP Housing, Bulihan, Silang, Cavite
Cel #: 09297149639 / 09194624361

____________________________
Date

TO WHOM IT MAY CONCERN:

This is to certify that based on our record,

_______________________________________ who was confined/admitted at
JULLIENNE LYING-IN AND MATERNITY CLINIC from _________________ to
________________ had no Medicare deductions for hospital charges including
professional fees upon discharge. All hospital charges and professional fees to the
amount of ____________________________________________________________
( ) were fully paid by the patient/member under ) Official Receipt
No/s. ___________.

This waiver is being issued upon the request of

_____________________________________________ for whatever legal purpose it
may serve.

RODELIZA F. EMPIALES
Lying-in Director