209, The Cocomall, Osmena Blvd.

, Cebu City 6000 PH

Trunkline: +632 255 0035 / +632 254 6729
Email: info@lifeandhealthhmp.com

AUTHORIZATION FORM FOR DOCTOR'S CONSULTATION ONLY

HOSPITAL/ CLINIC DATE ISSUED
03/21/2023
ATTENDING PHYSICIAN VALID UNTIL
DR. JAMES BERMAS 03/28/2023
MEMBER DETAILS
LAST NAME FIRST NAME EFFECTIVITY DATE
GARCIA EBENECIR 11/01/2022
COMPANY NAME BILL BACK EXPIRY DATE
FUSION BPO SERVICES PHILIPPINES INCORPORATED & TELESERVE No 10/31/2023
I.D. NUMBER AGE SEX
D20220000031402 64 MALE
PLEASE INDICATE THE APPROPRIATE CHIEF COMPLAINT, IMPRESSION/ DIAGNOSIS, DIAGNOSTIC PROCEDURES AND OTHER TESTS.
CHIEF COMPLAINTS IMPRESSION/ DIAGNOSIS

DIAGNOSTIC PROCEDURES AND OTHER TESTS

THE FOLLOWING CHARGES SHOULD BE COLLECTED FROM THE MEMBER

ANY AMOUNT IN EXCESS OF THE MEMBER'S COVERABLE AMOUNT MISCELLANEOUS CHARGES PPE Kit
OTHERS:

SPECIAL NOTES/ REMARKS APPROVAL CODE 227545

DENEB CAVADA
(System Generated Signature not Required)
NAME OF AUTHORIZED LOA ISSUER

DR. JAMES BERMAS

SIGNATURE OVER PRINTED NAME OF PHYSICIAN
DECLARATION
I acknowledge that the liability of Life & Health HMP, Inc. shall
be limited to the stipulations in the Memorandum of Agreement.
Any misrepresentations, concealment of vital information, fraud,
shall void this agreement and render it ineffective but only
insofar as the particular individual is concerned, without any
obligation on the part of Life & Health to reimburse any part
of the medical expenses and without prejudice to any legal
action, civil, or criminal that may be instituted by the offended
party.
If the amount of my previous availment is not yet reflected at the
time of issuance of the Letter of Authorization (LOA), Life &
Health reserves the right to make the final decision on my
coverage based on the remaining balance of my benefit
limit.
DATE SIGNED
I hereby authorize Life & Health to collect from me any
expenses incurred relative to the circumstances indicated in this
Declaration, regardless of whether they were discovered at
the time of treatment, or if found after Life & Health's
post-verification and confirmation.
I hereby give my full consent to Life & Health to access,
receive and process copies of my medical records which any
of its authorized representatives may request from any medical
institution/ facility/ practitioner, in connection with the
medical services provided to me by them; Provided that Life &
Health shall process such data in accordance with the Data
Privacy Act.

GARCIA, EBENECIR Y
SIGNATURE OVER PRINTED NAME OF MEMBER AUTHORIZED GUARDIAN OF MEMBER/ RELATION TO MEMBER
ORIGINAL (WHITE)- MUST BE RETURNED TO LIFE HEALTH HMP, INC. • DUPLICATE (YELLOW)- MUST BE RETAINED BY HOSPITAL/LABORATORY

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