PhilHealth CSF (lai Slanat IMPORTANT REMINDERS: Ferm) PART | MEMBER AND PATIENT INFORMATION AND CERTIFICATION 1 Pies lerston Nurer PIN of ene. ~ ~U 2. Nar of Mende: baer tot Bit Lo-bod-Lid —Gailane Fis ane Te Nave wae: Dla Gz, Juan, Si) (nat 7 Seas {piven crteton unter Pm) lSeperéet | | u 5. Nar af Pater 6. Ralatonip to Menber: Dents Cleat D spouse “Tttione Fist fame Md Nan example: Ds Ga, Joan I, Sa) 1.Canfnement Petit aoaeamies Ly J-LyJ- e-paeoeepes LJ- Li J- arom oveeteem: Ly JL, |- (natty) (nsaryya) (nay 7 £. CERTIFICATION OF MEMBER: Under the penalty ofa, Latest tha the information provided in this Form are true and accurate tthe Best of my knowledge [Sai is Sata eat Sis {ecb epee Restate spouse Clons Caer Sage Sacer eet Cletig C1 onan azn fr sgrngon 1 Werner incspactatee Cimeroer 1] Reoresetative reat eter ottarrsason PART Il EMPLOYERS CERTIFICATION (or enployad menbers ony + Pineal Ne PEN - LJ zeman 2. Businas Name 4. CERTIFICATION OF EMPLOYER: This to certly that al monthly premium contributions for and in behalf ofthe member, while employed inthis company, Including the applicable tree (3) monthly premium contributions within te past six (6) months period prior tothe fist day ofthis confinement, have Been deductedcollected and remitted to PhiMealt, and that the Information supplled by the member or hither representative on Part | are consistent wit ou available records Ld -Lit-Lot Sara Pia eco Rao 5 Capeciy [Deignafon Oe Sar mn ra PART Il- CONSENT TO ACCESS PATIENT RECORDIS ‘haa consant tothe examination by PRI of pains mol ecard forthe purpose of ering the veracity of is lim. haa tld Pitt or anya ofr, employes andor representatives sm any and al Iblis tothe rset onsen ich have voluntarily and wing ivan in conection with his cnn for reimbursement before hiteath Sapte ra Prd Nara ot er Feta aba arn Lo-Lo-Luw oaaee FA somse Foi Part {ptr pena lo wt, 5 retin” sia Cl cransc___ ium asap cee Alton Chem Cy RomePART I= HEALTH CARE PROFESSIONAL INFORMATION "aaa = =U Aeon ~ “oO LJ-LiJ-Li! Lod-L Ibid De Sed mr i Sere rnhap se Accebtati o. . -U LJ-LJ-Li! Da Send ont a PART V - PROVIDER INFORMATION AND CERTIFICATION, Feary tht sans rendre wor racorded nthe patent chrt nd het crinetton records nd ht hha ifrmaton he ae re and coect WLU LL