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    LOA-21-1935 - Rolex M. Delos Lado

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    Lexilyn Delos Lado
    This letter of authorization is for Rolex M. Delos Lado to undergo various medical tests and procedures at Halcyon Health Network Inc. on November 4, 2021. The tests include a CBC with platelet count and other blood tests. Halcyon Health Network will be paid directly and the patient will not receive any billing documents. The letter is only valid for the day of the scheduled tests and procedures. Medical reports should be emailed to three specified doctors after the consultation. Meals for the patient will be at their own cost while medical expenses will be charged to Halcyon Health Network.

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    LOA-21-1935 - Rolex M. Delos Lado

    Uploaded by

    Lexilyn Delos Lado
    15 views1 page
    This letter of authorization is for Rolex M. Delos Lado to undergo various medical tests and procedures at Halcyon Health Network Inc. on November 4, 2021. The tests include a CBC with platelet count and other blood tests. Halcyon Health Network will be paid directly and the patient will not receive any billing documents. The letter is only valid for the day of the scheduled tests and procedures. Medical reports should be emailed to three specified doctors after the consultation. Meals for the patient will be at their own cost while medical expenses will be charged to Halcyon Health Network.

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    LOA-21-1935_Rolex M. Delos Lado (2)

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    This letter of authorization is for Rolex M. Delos Lado to undergo various medical tests and procedures at Halcyon Health Network Inc. on November 4, 2021. The tests include a CBC with platelet count and other blood tests. Halcyon Health Network will be paid directly and the patient will not receive any billing documents. The letter is only valid for the day of the scheduled tests and procedures. Medical reports should be emailed to three specified doctors after the consultation. Meals for the patient will be at their own cost while medical expenses will be charged to Halcyon Health Network.

    Copyright:

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

    LOA-21-1935 - Rolex M. Delos Lado

    Uploaded by

    Lexilyn Delos Lado
    This letter of authorization is for Rolex M. Delos Lado to undergo various medical tests and procedures at Halcyon Health Network Inc. on November 4, 2021. The tests include a CBC with platelet count and other blood tests. Halcyon Health Network will be paid directly and the patient will not receive any billing documents. The letter is only valid for the day of the scheduled tests and procedures. Medical reports should be emailed to three specified doctors after the consultation. Meals for the patient will be at their own cost while medical expenses will be charged to Halcyon Health Network.

    Copyright:

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

    LOA-21-1935

    DATE
    LETTER OF AUTHORIZATION 4-Nov-2021
    NAME OF PATIENT
    Rolex M. Delos Lado
    NAME OF FACILITY
    Halcyon Health Network Inc
    CONSULTATION/EXAMINATION/PROCEDURE REQUEST
    CBC with Platelet Count, Ferritin, Iron, TIBC, LDH, Bilirubins (Total, B1, B2), TPAG and
    Ratio, Calcium, ESR, Fecalysis with FOBT - 8:00 AM
    SPECIALIST/ATTENDING PHYSICIAN DIRECT REFERRAL

    OTHER INSTRUCTIONS

    *We request that no billing documents (Statement of Account/Charge Invoice) shall be issued by the Billing
    Department - Cashier to the patient.

    We guarantee further that payment will be settled from our end.

    Kindly note that this LOA is valid only on the day of test/procedure. Please coordinate with any of our personnel
    at 0917-634-4202/0917-160-5377 / 0920-538-2633/0919-436-3539 if you have any concerns.
    FOR CONSULTATION, MAY WE REQUEST FOR A MEDICAL REPORT AFTER. Email to the following:

    Medical Director : marilarmd@shiptoshore.com.ph


    Post Medical Doctor 1 : postmd1@shiptoshore.com.ph
    Post Medical Doctor 2 : postmd2@shiptoshore.com.ph

    Prepared by: Karen V. Gratuito

    Accounting Assistant

    Noted by: MARILAR F. DE GUZMAN, MD

    Medical Director Post Medical Doctor

    IMPORTANT ( Instruction for Patient Admission): Medical expense of the patient will be charged to our account. Meals or any food
    ordered will be at the patient’s cost.

     3/F, Maria Cornelia Bldg. 222 Sen. Gil Puyat Ave., Makati City, Philippines
    Contact Nos.: 0917-634-4202/0917-160-5377 / 0920-538-2633/0919-436-3539

    SSMA Form No. PRM - 76 - 01 (07/23/19)

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