24/7 Customer Service Hotline: +63 (2) 8462 1800

Outside Metro Manila (toll-free for PLDT):

LETTER OF AUTHORIZATION TO PROVIDER 1-800-1888-3230
FOR CONSULTATION SERVICES
Type of Consultation m INITIAL m FOLLOW UP m CLEARANCE
OP No. : 03415329
Date Issued 01/19/2024 Valid From 01/19/2024 Valid Until 01/21/2024
Hospital / Clinic CLINICA ANTIPOLO HOSPITAL & WELLNESS CENTER APPROVAL CODE

Unit / Department DR. MA LOURDES SIMEON 2 0 2 4 0 1 1 9 GEN 0 0 6 2 1

Patient Name ALAIZA FRANCISCO
Generated via HeyPhil
Certificate No. A10NOB0 Age 29 Sex FEMALE (Signature not required)
Company Name Name & Signature of Authorized OP Coordinator / LOA Issuer
INTEGRATED CALL CENTER SOLUTIONS PHILIPPINES, INC.
Effectivity Date 10/01/2023 Expiry Date 09/30/2024 CLINICA ANTIPOLO HOSPITAL & WE
Attending Physician DR. MA LOURDES SIMEON Issuing Hospital / Clinic

INSTRUCTION TO PHYSICIAN For strict compliance, kindly indicate the pertinent chief complaint and daignosis/impression.

CHIEF COMPLAINT DIAGNOSIS / IMPRESSION

Bleeding REASON FOR CONSULT NOS (V65.9)

IMPORTANT For strLaboratory/Diagnostic Procedures are NOT ACCEPTABLE DR. MA LOURDES SIMEON
if indicated above, thus nullifies this document.
Name & Signature of Physician Date Signed

THE FOLLOWING CHARGES SHOULD BE COLLECTED FROM THE MEMBER

m Co-payment Arrangement: %(percentage) of the total charge (HB + PF) , or then amoount of .

m Others, please specify:

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

A FRIENDLY REMINDER : Please call your

provder prior to availment service/s

Room No Name & Signature of Member, or Guardian Date Signed

Schedule
If relative, relationship to the member;
Contact No

Original Copy - Must be returned by Physician / Hospital / Clinic to PhilCare Duplicate Copy - Must be retained by Physician / Hospital / Clinic

24/7 Customer Service Hotline: +63 (2) 8462

LETTER OF AUTHORIZATION TO PROVIDER 1800
Outside Metro Manila (toll-free for PLDT):
FOR CONSULTATION SERVICES
Type of Consultation m INITIAL m FOLLOW UP m CLEARANCE OP No. : 03415329
Date Issued 01/19/2024 Valid From 1/19/2024 9:05:31AM
Valid Until 01/21/2024
Hospital / Clinic CLINICA ANTIPOLO HOSPITAL & WELLNESS CENTER APPROVAL CODE

Unit / Department DR. MA LOURDES SIMEON 2 0 2 4 0 1 1 9 G EN 0 0 6 2 1

Patient Name
ALAIZA FRANCISCO Generated via HeyPhil
Certificate No. (Signature not required)
A10NOB0 Age 29 Sex FEMALE
Company Name Name & Signature of Authorized OP Coordinator / LOA Issuer
INTEGRATED CALL CENTER SOLUTIONS PHILIPPINES, INC.
Effectivity Date 10/01/2023 Expiry Date 09/30/2024 CLINICA ANTIPOLO HOSPITAL & WE
Attending Physician DR. MA LOURDES SIMEON Issuing Hospital / Clinic

INSTRUCTION TO PHYSICIAN For strict compliance, kindly indicate the pertinent chief complaint and daignosis/impression.

CHIEF COMPLAINT DIAGNOSIS / IMPRESSION

Bleeding REASON FOR CONSULT NOS (V65.9)

IMPORTANT For strLaboratory/Diagnostic Procedures are NOT ACCEPTABLE DR. MA LOURDES SIMEON
if indicated above, thus nullifies this document. Name & Signature of Physician Date Signed

THE FOLLOWING CHARGES SHOULD BE COLLECTED FROM THE MEMBER

m Co-payment Arrangement: %(percentage) of the total charge (HB + PF) , or then amoount of .
m Others, please specify:

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

A FRIENDLY REMINDER : Please call your

provder prior to availment service/s

Room No Name & Signature of Member, or Guardian Date Signed

Schedule
Contact No If relative, relationship to the member;

Original Copy - Must be returned by Physician / Hospital / Clinic to PhilCare Duplicate Copy - Must be retained by Physician / Hospital / Clinic