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INSTRUCTION TO PHYSICIAN For strict compliance, kindly indicate the pertinent chief complaint and daignosis/impression.
IMPORTANT For strLaboratory/Diagnostic Procedures are NOT ACCEPTABLE DR. ANTONIO FALTADO JR
if indicated above, thus nullifies this document.
Name & Signature of Physician Date Signed
m Co-payment Arrangement: %(percentage) of the total charge (HB + PF) , or then amoount of .
DECLARATION
I acknowledge that PhilCare's liability is strictly limited to the provisions of the Agreement, and it reserves the right to deny any claim or coverage that is (a)due to misrepresentation; (b)due to an exclusion; or (c)otherwise not in
conformity to the Agreement; (d)as a result of any handwritten notation or superimposition on this document. Any expenses thus incurred will be charged to me.
I hereby authorize PhilCare to receive and process any medical information that is relevant to this Letter of Authorization, in connection with the evaluation and grant of my benefits under PhilCare. A certified photocopy of this
Original Copy - Must be returned by Physician / Hospital / Clinic to PhilCare Duplicate Copy - Must be retained by Physician / Hospital / Clinic
INSTRUCTION TO PHYSICIAN For strict compliance, kindly indicate the pertinent chief complaint and daignosis/impression.
IMPORTANT For strLaboratory/Diagnostic Procedures are NOT ACCEPTABLE DR. ANTONIO FALTADO JR
if indicated above, thus nullifies this document. Name & Signature of Physician Date Signed
DECLARATION
I acknowledge that PhilCare's liability is strictly limited to the provisions of the Agreement, and it reserves the right to deny any claim or coverage that is (a)due to misrepresentation; (b)due to an exclusion; or (c)otherwise not in
conformity to the Agreement; (d)as a result of any handwritten notation or superimposition on this document. Any expenses thus incurred will be charged to me.
I hereby authorize PhilCare to receive and process any medical information that is relevant to this Letter of Authorization, in connection with the evaluation and grant of my benefits under PhilCare. A certified photocopy of this
Original Copy - Must be returned by Physician / Hospital / Clinic to PhilCare Duplicate Copy - Must be retained by Physician / Hospital / Clinic