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    FLC Reim Pablo, Alfed Allan 7.31.19

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    Annilyn Velasco Miraballes
    The document is a medical reimbursement form for Alfred Allan Pablo. It lists his diagnosis of UTI and diarrhea at 16 weeks pregnant. It shows that he had two doctor consultations on July 13th costing 500 pesos each and purchased Dolan Forte from Rose Pharmacy for 139 pesos. The total coverable amount is 139 pesos. The form was prepared by Annilyn Miraballes and approved by Dr. Benjamin Sanchez.

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    FLC Reim Pablo, Alfed Allan 7.31.19

    Uploaded by

    Annilyn Velasco Miraballes
    9 views1 page
    The document is a medical reimbursement form for Alfred Allan Pablo. It lists his diagnosis of UTI and diarrhea at 16 weeks pregnant. It shows that he had two doctor consultations on July 13th costing 500 pesos each and purchased Dolan Forte from Rose Pharmacy for 139 pesos. The total coverable amount is 139 pesos. The form was prepared by Annilyn Miraballes and approved by Dr. Benjamin Sanchez.

    Original Description:

    PHYSICAL ASSESSMENT

    Original Title

    Flc Reim Pablo, Alfed Allan 7.31.19

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    The document is a medical reimbursement form for Alfred Allan Pablo. It lists his diagnosis of UTI and diarrhea at 16 weeks pregnant. It shows that he had two doctor consultations on July 13th costing 500 pesos each and purchased Dolan Forte from Rose Pharmacy for 139 pesos. The total coverable amount is 139 pesos. The form was prepared by Annilyn Miraballes and approved by Dr. Benjamin Sanchez.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as xlsx, pdf, or txt
    9 views1 page

    FLC Reim Pablo, Alfed Allan 7.31.19

    Uploaded by

    Annilyn Velasco Miraballes
    The document is a medical reimbursement form for Alfred Allan Pablo. It lists his diagnosis of UTI and diarrhea at 16 weeks pregnant. It shows that he had two doctor consultations on July 13th costing 500 pesos each and purchased Dolan Forte from Rose Pharmacy for 139 pesos. The total coverable amount is 139 pesos. The form was prepared by Annilyn Miraballes and approved by Dr. Benjamin Sanchez.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as xlsx, pdf, or txt
    of 1

    Date: 7/31/2019

    Name: PABLO, ALFRED ALLAN F.


    Company: FILOIL LOGISTIC CORP
    HPPI ID # 16-00001-0067
    Availment Date:
    Admission Date:
    Discharge Date:
    DIAGNOSIS: UTI, DIARRHEA, 16 WKS AOG

    Nature of Reimbursement: FMA/POS

    Name of Supplier
    / Clinic / Coverable
    O.R. Date O.R. Number Hospital Particulars Price Amount Remarks

    6/8/2019 CONSULT 250.00

    DR. ELSIE YAP-


    7/13/2019 0135 ICAMINA CONSULT 500.00

    DR. MARY GRACE


    7/13/2019 0179 BRIONES CONSULT 500.00

    7/13/2019 000310457029 ROSE PHARMACY DOLAN FORTE 139.00

    TOTAL 139.00

    Prepared by: ANNILYN V. MIRABALLES Approved by: DR BENJAMIN SANCHEZ


    Date 7/29/2019 7/29/2019

    Noted:

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