MAP PAYMENT FORM) HRD-MAP-Form-02 February 7, 2022 (Medical Assistance Program) DATE The Manager Human Resources Department Attached are the following documents for processing of payment: Reimbursement of expenses of “LI Financial Assistance for L) Hospitalization Corrective Lenses Consultation (©) Executive Check-up ( Laboratory [J Onthodontic/Dental L [CI Others _ __ Of undersigned / 5 (Name of Qualified Dependent) __ (Relationship) (Age) The amount of Php , in accordance with Board Resolution No. 0162 series of 2021 or the PCSO Medical Access Program (MAP). The undersigned is a permanent employee since assigned at the (Department/Office.) Respectfully yours, (Signature over Printed Name) —_—_— SSF To be accomplished by the MAP Unit MAP BALANCE Beginning Balance: Php100,000.00 Date of Last Particulars ] ‘Amount | _ Current Balance _Availment _ _ (Please refer to the attached Employée Ledger Balance for details of MAP availments) (2 Officiavempioyee has rendered at least 3 months of service with PCSO (1 No Pending Administrative Case or pending case for investigation (© Undergone the Annual Physical and Dental Examination for employee (1) Has been vaccinated against Covid-19. MAP EvaluatorSUMMARY OF OFFICIAL RECEIPTS/ | HRD-MAP-Form-03 February 7, 2022 STATEMENT OF ACCOUNTS. (Medical Assistance Program) ‘SUMMARY OF OFFICIAL RECEIPTS/STATEMENTS OF ACCOUNTS DATE “ORNO./SO.A._| AMOUNT [PARTICULARS (Signature Over Printed Name) REMARKS, MAP Evaluator