“TivTornmaybereracucedand epi of he Pres "NOT FORSALE rertor PHILIPPINE HEALTH INSURANCE CORPORATION S PhilHealth cca Clete kine per F — eri cnr go gh (Claim Signature Form) eet ers cra Ren CDE ect vee eat rr 0 oncx ne i roraUTE AOS ite tera wel va eee Pele emi a tn rca rassmcinacT canon cre ecto Sa BESSY TCLS EA US LABLTES 1.PhilHealth Identification Number (PIN) of Member: [T+ TTT T1111 +1 2.NameofMember: 3. Member Date of Birth: ome, Ge Cpolo (expeLACRUE UAE) 4.PhilHealth identification Number (PIN) of Dependent:[T]-[TTT1TTLLLI 5. Name of Patient: 6.Relationship to Member: (ewe Dearne (] soase FirstName Fisthame Tame xerson ‘Micdle Name. esa (ex DUA CRUT JUAN PAG) 17. Confinement Period: soem CEE ew FOO | eco Patient Date of Birt 9, CERTIFICATION OF MEMBER: Under the penaity of law, attest that the information I provided in this Form are true and accurate tothe best of my knowledge. ‘Signature Over PrintegNameo! Member ‘Signature Over Printed Name of Member's Representative onesine CTC onesoet TPCT ae C nineoinacanemabna cea Fe cn rt eee. inte ae A ‘shouldbe assistedby an HCIrepresentative. tiveteemembe siting pias ee, eel or tcatcviem Cliteiebhonited [)ienter [_]aeeeseeatve behaloftemenber cher eases: 1.PhilHealthEmployerNumber(PEN):[F]-[ PPP PPPPP](9) 2.ContactNo.: 0002166457 3. Business Nam DEPARTAENT OF EDUCATION oepE) sins Nae of Employer 4, CERTIFICATION OF EMPLOYER: “Ths cet tat rosea renin crates teas Gmonscenbtan precedent lying canbe tin 2 mnt period ot fst conaman cafe rogaryarebue epee PCa Hoar bcimesmatonappbdbytve emia or Matnetap certain Patanecoset nour trata acade: _ROSALNDAN, DIONIO _ Adniintne Offers mesons TTT TT enh Gay year ‘Siguture Ove Printed Mame of Eployer/Authried Representative ‘Official Capacty/ Designation rey consent the sabmslonanderaraonc! he pater sprtheat medal records othe purpose! verge each f Naim eeceMcert procecingof benef payment. FrrebholoPhitesth ranyorts fears employesand/or representatives fenen lege iablivesrebvete the herer-mentned content ch have ‘leary anawitinghy enim comneson tn cn arrimursomantbare PRIME F TF) coon Datsioed ~ Sipe Over Prtccnane habe Pen aR swath Gay member eesentatetsabletovte, felavorsnpottne [Cseane Come Cine gh tunomar Herb Regret ecteaa hari % : Bodie nssedbyantreneasinve mocetbortet: | fottiog [|e eect —_. Precktne seep te. rementorsgringon [J patentsincapactated Corset _Jreprseenive vehaor theater eras credtation wl TTT ILE TT 111 +b _ atestaned [T J-[ TIL D a O —~ sei ine GO wwe, COO) i CoH ase Oo ‘Signature Over Printed Name pen - cH oyu CCcoW F Datesigned CoH co orm tatonte Co DO ‘Signature Over Printed Name month day 1.PhilHealthBenefits: ICD1DorRVSCode: 1. ist CaseRate __ 2 SecondCase Rote {eertty tht services rendered wererecordedn the patetscartandeslcareinstition recorsandthattheberela nfrmellon given ore true andeorec ———_____. Date signed CH Coo ‘SiratureOverPrintedNemeotAuthorizedCIRepresentative ‘fia CapacyDesgratonere pei of Pais &, ms PHILIPPINE HEALTH INSURANCE CORPORATION F 1 PhilHealth Cite Conse 78 Shaw Besleverd, Pasig City Cc ™ De ete caf Ene G2 Trine oe se wn hie go coi: nse Sl 798 eves Septber2018 sees TT TT ETL THPORTANT REMINDERS: PLEASE WRITE IN CAPITAL LETTERS AND GHEGK THE APPROPRIATE BOXES. For loca avallment. this form loethe wth ther PiHeath lim forms ard other supporting documents should be ted within 60 days from date of charge, For avaliment of henofis abroad, tis frm togthor wih oer suppeting docur-erts should be fled within 180 days from date of ischarge. Representative of he Heath Care inttutons (HC!) shall assist the member fauthorized representative in filing out his form. ‘Alinformation cequed inthis form are necessary Cam forms wih incorplte formation shal not be processed. FALSE/INCORRECT INFCRMATION OR MISREPRESENTATION SHALL BE SUBJECT TO CRIMINAL, CIVIL OR ADMINISTRATIVE LIABILITIES. Pen Seo 4. PhilHealth Identification Number (PIN) of Member:{_| | J TT TT TV TEC] 2, Name of Member: TatNane Frsitame Tame Sxenalon ‘Wid Nene ty (ec DEACRIZ UAL SRG 4, Malling Address: ailRoon NosFiow: ‘Buking Nome avi onwe GN Siew Sbantlage Boros ‘Cryo Proinee Coury Zpcose 6. Contact information: Lande No, Area Code Tet No) Emat Adsress 1. Philiealth entiation Number (IN) of Dependent: [TTT 11111111 CJ 2. Name of Patient: 3. Date of Birth: Io IL mo LastName First Name Name Exension Waidle Name ‘on as (orD.ACA HAN RSP) aay 4. Relationship to Member:[Jonts []oasrt [spouse See cecaenae Under the penalty of law, | attest that the information | provided in this Form are true and accurate to the best of my knowledge. ‘Signature Over Painted Name of Member ‘Signature Over Printed Name of Member's Representative cate sired TTT JL TL) ete saree T +11 ‘month day mosh day ‘year t merbestepresantave tunable to wre, Relationship of the [spouse [Joni [7] parent paral hunter MarbarRepresene represenatve tothe member [] siting a ‘old be esse by a HCI opreseisive Check te appropiate box Reason fr signing on Member ie inespactated |[_Imemver |_JRepresentatve PART IV-EMPLOYER’S CERTIFICATION 4.PhilHealth Employer Number (PEN): FT PPP PPP PPTI3] 2 ContactNo.: (084) 216-6407 3. Business Name: DEPARTMENT OF EDUCATION (DepE6) ‘Business Name of Employer “4, CERTIFICATION OF EMPLOYER: This i to certy thatthe required 3/6 monthly premium contributions plus at eest 6 montis contributions preceding the 8 montrs qualying contibutions with 12 month period prior tte frst day of confinement (suficient regularity) have been regulary remitied fo PhiHeel®. etover te information suppied by the mersber or hisfher representative on Part! are consistent with our available records.” ROSALINDA N. DIONIO Administrative Officer V___ pate sinee__H1 Sats Ove Pied Nave of Employee Repose ‘Ofiel CapectyDesgraton ort ear CrCaa ero asl ns, oseke nae THIGIPRO Signetue Over Ported Neme