24/7 Customer Service Hotline: +63 (2) 462 1800

LETTER OF AUTHORIZATION TO PROVIDER Outside Metro Manila (toll-free for PLDT):

FOR LABORATORY & PROCEDURE SERVICES 1-800-1888-3230

OP No. : 03697633
Date Issued 04/17/2024 Valid From 04/17/2024 Valid Until 04/19/2024
Hospital / Clinic MEDICUS MEDICAL CENTER APPROVAL CODE

Unit / Department DR. PATRICK DEXTER BUENAFLOR 2 0 2 4 0 4 1 7 0 0 9 7 2

Patient Name MARY GRACE LOZADA
Certificate No. A0ZWAG0 Age 42 Sex FEMALE Gale, Krystel Joy
Name & Signature of Authorized OP Coordinator / LOA Issuer
Company Name CHICKEN ESSENTIALS INC. & AFFILIATES
Effectivity Date 07/28/2023 Expiry Date 07/27/2024 LIAISON OFFICER
Attending Physician DR. PATRICK DEXTER BUENAFLOR Issuing Hospital / Clinic

INSTRUCTION TO LOA ISSUER / OP COORDINATO Please indicate pertinent diagnosis/impression and the diagnostic & other services.

DIAGNOSIS / IMPRESSION DIAGNOSTIC AND OTHER SERVICES LIMITS

Asthma (J45) #SIMPLE SPIROMETRY WITH PRE & POST AUTHORIZED LIMIT 10000
BRONCHODILATOR INNER LIMITS (if any)

Peso Count
1.

2.

3.

THE FOLLOWING CHARGES SHOULD BE COLLECTED FROM THE MEMBER

m Co-payment Arrangement: %(percentage) of the total charge

m Prosthetics device, corrective appliances, m Others, please specify
(HB + PF) , or then amoount of . and artificial devices
m Charges in excess of member's coverable amount . l Philhealth cost equivalent (if member did not file)

DECLARATION
I acknowledge that PhilhealthCare, Inc's ("Philcare") liability is strictly limited to the provisions of the Membership Agreement ("Agreement"), and it reserves the right to deny any claim or coverage resulting fron (a)
misrepresentation; (b} exclusion; ot (c) non-conformity to the Agreement. Any resulting expense thus incurred will be charged to me.

I hereby consent, without prior notification to the processing, storage and disclosure by PhilCare, its authorized employees and representatives, of all personal, sensitive personal and medical information shared by it or its
members, for all purpose relevant to this Letter of Authorization and to tha Agreement, including but not limited to the evaluation and grant of my benefits under PhilCare. Said information may also be utilized by PhilCare to promote
other products and services that may be related to those provided in the Agreement. Said consent extends likewise from those persons whose information has been provided, whose consent has been properly secured. I
understand and agree that: (i) a certified photocopy of this Letter of Authorization shall not be honoured as the original; (ii) the Letter of Authorization is NOT a guaranteel and (iii) all claims are subject to the final diagnosis.

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

First copy - for Philcare; Second copy - for the Physician/Hospital/Clinic

24/7 Customer Service Hotline: +63 (2) 462 1800

LETTER OF AUTHORIZATION TO PROVIDER Outside Metro Manila (toll-free for PLDT):
FOR LABORATORY & PROCEDURE SERVICES 1-800-1888-3230

OP No. : 03697633
Date Issued 04/17/2024 Valid From 04/17/2024 Valid Until
04/19/2024
Hospital / Clinic MEDICUS MEDICAL CENTER APPROVAL CODE

Unit / Department DR. PATRICK DEXTER BUENAFLOR

2 0 2 4 0 4 1 7 0 0 97 2
Patient Name MARY GRACE LOZADA
Certificate No. A0ZWAG0 Age 42 Sex FEMALE Gale, Krystel Joy
Company Name CHICKEN ESSENTIALS INC. & AFFILIATES Name & Signature of Authorized OP Coordinator / LOA Issuer

Effectivity 07/28/2023 Expiry Date 07/27/2024 LIAISON OFFICER

Date
Attending Physician DR. PATRICK DEXTER BUENAFLOR Issuing Hospital / Clinic

INSTRUCTION TO LOA ISSUER / OP COORDINATO Please indicate pertinent diagnosis/impression and the diagnostic & other services.
DIAGNOSIS / IMPRESSION DIAGNOSTIC AND OTHER SERVICES LIMITS
Asthma (J45) #SIMPLE SPIROMETRY WITH PRE & POST
AUTHORIZED LIMIT 10000
BRONCHODILATOR INNER LIMITS (if any)

Peso Count
1.

2.
3.

THE FOLLOWING CHARGES SHOULD BE COLLECTED FROM THE MEMBER

m Co-payment Arrangement: %(percentage) of the total charge m Prosthetics device, corrective appliances, m Others, please specify
(HB + PF) , or then amoount of . and artificial devices
m Charges in excess of member's coverable amount . l Philhealth cost equivalent (if member did not file)

DECLARATION
I acknowledge that PhilhealthCare, Inc's ("Philcare") liability is strictly limited to the provisions of the Membership Agreement ("Agreement"), and it reserves the right to deny any claim or coverage resulting fron (a)
misrepresentation; (b} exclusion; ot (c) non-conformity to the Agreement. Any resulting expense thus incurred will be charged to me.

I hereby consent, without prior notification to the processing, storage and disclosure by PhilCare, its authorized employees and representatives, of all personal, sensitive personal and medical information shared by it or its
members, for all purpose relevant to this Letter of Authorization and to tha Agreement, including but not limited to the evaluation and grant of my benefits under PhilCare. Said information may also be utilized by PhilCare to promote
other products and services that may be related to those provided in the Agreement. Said consent extends likewise from those persons whose information has been provided, whose consent has been properly secured. I
understand and agree that: (i) a certified photocopy of this Letter of Authorization shall not be honoured as the original; (ii) the Letter of Authorization is NOT a guaranteel and (iii) all claims are subject to the final diagnosis.

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

First copy - for Philcare; Second copy - for the Physician/Hospital/Clinic