Medical Referral Office – Quezon City Medical Referral Office / Provider Relations Office– Global City

St. Luke’s Medical Center-Quezon City St. Luke’s Medical Center-Global City
CHBC North Tower Room 718 Medical Arts Bldg. (MAB) Room 725-726
Trunk line: (632) 723-0101 Local 5718 Trunk line: (632) 789-7700 Local 7725 / 7726
Direct line: (632) 726-5770 Direct line: (632) 8467508
Fax: (632) 726-6130 Fax: (632) 846-6335
Office Hours: 8 AM-5 PM, Monday-Friday Office Hours: 8 AM-5 PM, Monday-Friday

MEDICAL REPORT
(Note to TakeCare Physician Provider: This serves as your PROFESSIONAL FEE SLIP)

PATIENT’S NAME: Last: _______________________ First: ______________________ Middle: ___________________

DESCRIPTION OF SERVICES:
[ ] OUTPATIENT [ ] INPATIENT
[ ] Consultation [ ] Medical Management
[ ] Pre-Operative Clearance [ ] Surgical Procedure / Management
[ ] Surgical Procedure [ ] Non-Surgical / Diagnostic Procedure
[ ] Non-Surgical / Diagnostic Procedure [ ] Anesthesia / Sedation
[ ] Anesthesia / Sedation
DATE/S OF SERVICE/S: FACILITY: [ ] SLMC - QC [ ] SLMC - GC [ ] MMC
[ ] CDUH [ ] TMC - ORTIGAS [ ] TMC - CLARK
[ ] TMC- ILOILO [ ] OTHERS ___________________
CLINICAL INFORMATION:
Clinical History and Findings (Please attach consult report, medical abstract, operative report, test results, etc.):

Diagnosis/es (Please include ICD-10 Code/s.): Procedure/s done (Please include CPT code/s.):
1. 1.
2. 2.
3. 3.
4. 4.
5. 5.

Plan / Recommendations / Prescribed Medication/s:

Note: Professional fee slips for services rendered must be submitted no more than forty-five (45) days from date of service or date of
discharge with appropriate and complete documentation necessary for review and pricing. Claims received after forty-five (45) days
from date of service filing limit will be denied as stale billing.

_______________________________________________ _____________________________
PHYSICIAN’S NAME AND SIGNATURE / DATE E-mail Add. / Contact Info

White – TakeCare Copy Pink – Patient’s Copy Blue – Physician’s Copy

PI_MRO form_2014