Republic of the Phiippines
PHILIPPINE HEALTH INSURANCE CORPORATION
Ena CMe HEALTH INSURANCE CF
Storms nettanit MD
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MEMBER DATA RECORD
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MEMBER INFORMATION = —
Phitttealth Identification Number (PIN): 020509763071
Member Category FORMAL ECONOMY NHTS Coverage
Sub-Category PRIVATE Efiectvity Period
FERNANDO, MICHAEL ANGELO DE QUIROZ c
BGY 46, PASAY CITY, FOURTH DIST, 1200
Foreign Address : NA Sex Male
Date of Birth o4/or/t995
: Place of Binh asay cy ¢
Contact No, (Foreign): NIA Civil Status SINGLE
(Local) Tax Identification Ni 818216626
EMPLOYER/ORGANIZED GR aan
Priealth Number (PENPOGN) 1007000008005
Name of Employer/Organized Group: SERBIZ MULTI PURPOSE COOPERATIVE
Business Address {NIT 20) SAN BUENA BLOG 9 SHAW BLVD, SAN ANTONI, FASIGCTY, SECONDDOISTRNT
Telephone Number 045 4553381
Tax Identification Number
DEPENDENT INFORMATION
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Middle Name
(O DECLARED DEPENDENTIS|
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NOTHING FOLLOWS ***
Tse] Reston [Date afaiah
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i LEILANIE CHERRILINA JOY V, ASPRER, M.D. io
OIC - Branch Manager
NCR South Las Pitas
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Paalala : Basahin ang nilalaman ng MDR. Kung may kulang o mall, balk agad upang maldagdag o malwvast.Ingatan ang onhinal na
kopya at huwag ibigay kahit kanino. Kung sakaling gagamit at makikinabang ng benepisyo, magh gay ng kopya sa pital. meno
creer fhe MOR Soi thare be ay da deepak bck aed ore the ee Tae go art
Prove pocepy host n ase conser and aanet bevels),
This is a system generated report. Signature is not required.
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