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    Annex A Legislators Endorsement Form

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    Mkdb Chavez
    The document is a medical assistance endorsement form for an indigent patient named Christine D. Ramos. It provides her personal details including her age, birthdate, address, diagnosis of a right greater trochanteric fracture secondary to a fall, and a monthly household income of 10,000 pesos. The form requests 50,000 pesos in financial assistance for her hospital bill at Las Piñas Doctors Hospital. It notes that all patient details must be filled in completely for the new system to generate any report or guarantee letter.

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    Annex A Legislators Endorsement Form

    Uploaded by

    Mkdb Chavez
    1 views1 page
    The document is a medical assistance endorsement form for an indigent patient named Christine D. Ramos. It provides her personal details including her age, birthdate, address, diagnosis of a right greater trochanteric fracture secondary to a fall, and a monthly household income of 10,000 pesos. The form requests 50,000 pesos in financial assistance for her hospital bill at Las Piñas Doctors Hospital. It notes that all patient details must be filled in completely for the new system to generate any report or guarantee letter.

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    Annex a Legislators Endorsement Form

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    The document is a medical assistance endorsement form for an indigent patient named Christine D. Ramos. It provides her personal details including her age, birthdate, address, diagnosis of a right greater trochanteric fracture secondary to a fall, and a monthly household income of 10,000 pesos. The form requests 50,000 pesos in financial assistance for her hospital bill at Las Piñas Doctors Hospital. It notes that all patient details must be filled in completely for the new system to generate any report or guarantee letter.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    1 views1 page

    Annex A Legislators Endorsement Form

    Uploaded by

    Mkdb Chavez
    The document is a medical assistance endorsement form for an indigent patient named Christine D. Ramos. It provides her personal details including her age, birthdate, address, diagnosis of a right greater trochanteric fracture secondary to a fall, and a monthly household income of 10,000 pesos. The form requests 50,000 pesos in financial assistance for her hospital bill at Las Piñas Doctors Hospital. It notes that all patient details must be filled in completely for the new system to generate any report or guarantee letter.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    Annex A

    Republic of the Philippines


    Department of Health Office Logo
    MALASAKIT PROGRAM OFFICE

    MEDICAL ASSISTANCE TO INDIGENT PATIENTS ENDORSEMENT FORM


    Rep. Luis Raymund F. Villafuerte Jr.
    Name of Proponent: _______________________
    District/ Party List: _______________________
    2ND DISTRICT CAMARINES SUR
    PATIENT'S INFORMATION

    Date Middle Monthly Household Income Generated


    First Name Surname Age Birthdate Address Contact No. Diagnosis Hospital Assistance Needed Amount
    Name (Php) Code
    (mm/dd/yyyy) (mm/dd/yyyy) (Brgy., St. No., City)

    51 Bloodstone greater trochanteric Las Piñas


    05/25/2023 Christine D. Ramos 35 04/28/1988 Royale States Las 0926-203-3755 fracture, right 10,000.00 Doctors Hospital Bill 50,000.00
    Piñas City secondary to va Hospital

    NOTE:
    Kindly ask for patients' ID for verification purposes and fill in all the needed information. Our new system will not generate any report/guarantee letter if the details are not complete.

    Focal Person:

    Joan Tiozon
    Signature over Printed Name
    PAA III
    Contact Details

    KAYE ANN SAGLE


    Chief of Staff
    2nd District Camarines Sur
    MB-2F South Side, House of Representatives
    931-6718 / 931-5001 loc. 7499
    conglraystaffv2@gmail.com

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