e MEDICAL INFORMATION CENTER (MIC) Emali mic@istga.comph OUTPATIENT CONSULTATION FORM eo ec eoet [AVAILMENT DATE: LETTER OF GUARANTEE (LOG) [APPROVAL CODE: [APPROVED BY: losrtra024 lop-2s42-33800854 _|vilanuevarb IHOSPITALIGLINIG NAME IGENTRI MEDICAL CENTER AND HOSPITAL INC. PATIENT NAME: ace: [GENDER MORONG, MARICEL ARGUELLES las lFemale [COMPANY NAME: ID NO. [EXPIRY DATE: PLAN TYPE: |ANALOG DEVICES GEN. TRIAS, ING. (EMPLOYEES & 101-08431-279739-000 3012024 MPs TYPE OF CONSULTATION INITIAL FOLLOW-UP RANCE [CHIEF COMPLAINT PAST MEDIGAL HISTORY: RECOMMENDATION: PERTINENT PHYSICAL FINDINGS: [OTHER FINDINGS: FINAL DIAGNOSIS: TrvPE OF ILLNESS: JCONGENITAL, MATERNITY JACQUIRED JACCIDENT REMARKS: PLEASE ACCOMODATE PATIENT FOR CONSULTATION.THIS SERVE AS THE ORIGINAL LOG. THANKYOt PLAN MEMBER'S PRIVACY POLICY & CONSENT: | (or myeo and on bohalf of my dependents, andlor my authorized ropresentalve, authorize Etqal Philppines fo process my personal data, such ag, bilo! limited to. my medical dagnosialulizavon data and to asclose the sald personal data f| necessary tied partes sueh a, bul nol lied to, my employer accreted network providers, headuarter, raneurer, group poly holders and auditors finderstand thatthe processing of my personal data shall be used in servicing my account which includes, bul fs hal limited to the followng borefis| ladminstraton, medica treatment, and maragomont of the pian agree to recetve marketing Updates and afore. ragreo to oatan a copy of my recore| felatve ta my hospitalization, congultaion ang Veaiment or any other medical advice in connection with tne benef cam availed PLAN MEMBER'S UNDERTAKING & REMINDER! Plan Member must sigh AFTER avalment, Unused LOG should mmodiately be reported to Etgal Philppines Account Reconcilation Ext Ciearance. Final computation of our overage wi be made once Eiga Philppines Medical Clams Payables| Deparment adjadicates your cams considering ary ofthe folowing (a) any cal-ess avaliment (0) reimbursement claims: and (e) unprocessed ciaims| linat are yo to be biled by the accredited network providers. | agree that any availment may be defied under crcumstances such as concealment an| proceduies not related to the nese. | agree to sole for bildack ary incurred ilgible excess charges on benefits| render Elga Philippines free from any| abit on the colecton of the acquired excess chargos on benefits [ACCREDITED PROVIDER'S UNDERTAKING & REMINDER: lAccrodiied Network Provider must sign AFTER COMPLETION OF SERVICE. All proceduresitests must have prior approval fom Etiqa Philppines MIC. For immediate payment, pleaso submit al bile within 30 calendn’ ays, Accredited Network Provider shall naily eXlga Prippines f payment nol received within 30 calendar days from receipt of submitted bis, ia Life and General Assurance Philippines, Inc. and and 374 Floor Morning Star Center 347 Sen. Gil Puyat Avenue, Makati ity 1209 Tel Wo (632) 88902758, cil tebe TARR) cs Member