COOPERATIVE HEALTH MANAGEMENT FEDERATION

Rm.208-209 Malakas Suites, No. 88 Malakas St., Brgy. Pinyahan, Central District, Diliman, Quezon City, Philippines
Tel. Nos.: (02) 283-2321 * (02) 931-0387 Email Add: onecoophealth@gmail.com

LETTER OF AUTHORIZATION (LOA)

LOA Number: ____________

IMPORTANT : Please apply Philhealth / ECC benefits to all applicable expenses.

For any inquiry, please call Cooperative Health Management Federation.
Membership Assistance Department at Tel. # 283-2321 /931-0387

TO : ____________________________________________________ ADDRESS: __________________________________________

(HOSPITAL / CLINIC)

NAME : ____________________________________________________DATE : __________________________________________

COMPANY : __________________________________________________ MEMB. CARD #:_ ____________________________________

 EMERGENCY CARE TREATMENT Maximum Hospitalization Limit ______________

 OUT PATIENT / CONSULTATION A. Room Accommodation ______________
 CONFINEMENT B. Hospital Bill ______________
 OTHERS C. Professional Fee ______________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

* If patient is accommodated in a higher room category, member will shoulder all resulting incremental expenses in room and
board, in ancillary services and professional fees. Likewise, all miscellaneous, personal charges and take home medications and
other services not included in the Service Agreement must be charged accordingly before discharge.

___________________________________
COOP HEALTH AUTHORIZED SIGNATURE

Forward Hospital Bills within 30 days from discharge to Cooperative Health Management Federation at the above address.