Republic of the Philippines

PHILIPPINE HEALTH INSURANCE CORPORATION

PhilHealth Regional Office VII
th
8 floor, Golden Peak Tower, Gorordo Avenue cor. Escario St., Cebu City 6000

REQUEST FOR CHECK REPLACEMENT FORM No. _______

----Deceased Payee -xx-Lost Checks

----Stale Check ---- Typographical Error/Correction of Payee
----OFW Member ----Others ______________

Name of Member: Bindoy District Hospital PhilHealth No.________________

Name of Co-Claimant: Dr. Trifony D. Luchana, Chief of Hosp. Claim Series No._______________
Mailing Address: Bindoy, Negros Oriental Tel/Cellphone No.(035) 400-5409

Check Details:
Name of Payee Check No. Check Date Amount Date Cleared
1.Bindoy Dist. Hosp. 903771 12/7/12 P9,000.00 Jan.29,2013
2.Bindoy Dist. Hosp. 903772 12/7/12 21,000.00 Jan.25,2013
3.Bindoy Dist. Hosp. 903886 12/7/12 1,800.00 Jan.31,2013
4. Bindoy Dist. Hosp. 903887 12/7/12 4,200.00 Feb.26,2013
5.Bindoy Dist. Hosp. 904432 12/7/12 11,153.50 Jan.24,2013
6.Bindoy Dist. Hosp. 904645 12/7/12 23,100.00 Jan.16,2013
7.Bindoy Dist. Hosp. 904743 12/7/12 9,000.00 Jan.29,2013
8.Bindoy Dist. Hosp. 904744 12/7/12 21,000.00 Feb. 01,2013
9.Bindoy Dist. Hosp. 904895 12/7/12 4,900.00 Feb. 26,2013
10.Bindoy Dist.Hosp. 905912 12/8/12 4,200.00 Feb. 01, 2013
Total P109,353.50
Remarks: For replacement
DR. TRIFONY D. LUCHANA
Chief of Hospital I
Signature of Member/Co-Claimant Over Printed Name

VERIFIED ATTACHED SUPPORTING DOCUMENTS:

---2 valid Identification Cards of Member ----Letter Request issued by OFW member
---2 valid Identification Cards of Co-member ----MDR showing claimant as dependent
---Death Certificate of Member ----2 Valid Identification cards of member
---Marriage Contract/Certificate ----SPA valid during the member’s employment abroad
---Death Certificate of Member’s spouse ----Death Certificate of Parents
---Birth Certificate of Child/Children ----Birth Certificate of Siblings
---Marriage Certificate of Married Female Children ---Marriage Certificate of Married Female Siblings
---Notarized Adjudication of Sole Heir (if applicable)---Notarized Special Power of Attorney Executed by siblings
---Notarized Special Power of Attorney executed by children ----Birth Certificate of Member

SUBSCRIBED AND SWORN to before me this ____day of ___________, 2013, affiant

exhibiting to his Res. Cert. No. _____________dated ______________issued at ____________________.

(Person Administering Oath)

Doc. No _____
Page No.____
Book No.____
Series of ____