DRAFT:

PATIENT’S DETAILS

First Name:

Middle Name:

Last Name:

Age:

Birthday:

Address:

Estimated income of family:

Diagnosis:

Hospital:

Type of Assistance/ kinakailangang tulong:

Complete Name of Representative:

Relationship to the Patient:

Contact No.:

Email Add:

Ilakip ang mga sumusunod na requirements para sa DOH Guarantee Letter:

1. Government issued ID of patient;

2. Government issued ID of representative (with signature);

3. Latest Medical Abstract / Certificate;

4. Latest Prescription o Reseta ng gamot / Treatment Protocol;

5. Latest Hospital Bill / Promissory Note / Estimated Medical Cost o Quotation

Ilakip ang mga sumusunod na requirements para sa non-DOH hospital/Private:

1. Personal letter to Senator Joel Villanueva with signature and contact details;

2. Latest Barangay Certificate of Indigency under the name of the letter-sender/representative;

3. Copy of Government-issued ID with signature of the letter-sender/representative with 3 signature;

4. Copy of Government-issued ID of patient/subject of assistance;

5. Certified True Copy of Medical Abstract / Certificate;

6. Certified True Copy of latest Medical Quotation / Treatment Protocol;

7. Certified True Copy of Latest Hospital Bill (if still admitted) OR Certified True Copy of Promissory Note

Maraming salamat po sa inyong paglapit kay Senador Joel Villanueva.