CTS NO: Q05032024C1115569996

CONSULTATION / TREATMENT SLIP

Date Issued: 05/03/2024
Patient's Name:JAZMINE ROSE F. TRINIDAD
Contact No: 09982341766 Age: 28 Sex: FEMALE
Company: SOUTHFIELD AGENCIES, I.D. No.: 2673-00000015-02 Expiry Date:08-20-2024
Name of Hospital/Clinic/Laboratory: ALLIED CARE EXPERTS (ACE) MEDICAL CENTER-PATEROS, INC.
Diagnosis: hearing loss Date of Consultation/Treatment:

Treatment/Diagnostic Work-up (if any):

Please print two (2) copies. REMARKS:NOT VALID FOR TELECONSULTATION

Procedures and tests need approval from COCOLIFE at:

Helpline:(02) 8812-9090 or 8396-9000 / Short Messages Services (SMS) or text messaging at 0917-622-2626
Calls and SMS: 0917-536-0962 / 0908-894-7763 / 0922-898-8828

Approval is valid for 3 days from the issued date or before expiry date, whichever comes first. If beyond 3 days, please call for re-approval

This is a system generated eLOA. Signature and Name of Approver is not

Q05032024C1115569996
required.
Approval No. Name of Approver (COCOLIFE Representative)

*Member must present other identification (such as driver's license, company/school I.D.) to confirm identity.

UNDERTAKING, PRIVACY POLICY & CONSENT FORM:

By signing this form: (a) I understood and agree to the COCOLIFE Privacy Policy for the purpose of servicing my benefit plan; (b) I or my next kin hereby consent
COCOLIFE, its employees/representative to the collection, processing, storing, disclosure and sharing of my herein personal data, medical/health information and
utilization data from and to its accredited hospitals/clinics/health professionals, and to my company/employer for purposes of assessing my coverage, administration of
benefit plan, processing of any transaction necessary for the treatment of illness, conduct inquiry and obtain data pertinent to the herein availment, and for other
reasonable and legal purposes related to my plan; (c) acknowledge that the procedures indicated above have been done; (d) promise to pay COCOLIFE all expenses
not covered by the company's benefit plan; (e) render COCOLIFE free from any liability on the collection of the acquired non-coverable charges e.g. excess in limits,
exclusions, etc; (f) fully understand that I will be subjected to billback and adminstrative fees in case I fail to timely pay availments made outside the coverage of the
benefit plan; and (g) COCOLIFE and its employees/representative are hereby released from any and all liability in accordance hereto

This is a system generated eLOA. Signature Dr. ANTONIO, TOMAS S.

and Name of Approver is not required.

Patient/Legal Representative if patient Hospital/Clinic/Coordinator's Attending Physician Printed Name &

is below 18 years Representative Printed Name & Signature
Printed Name & Signature Signature

To facilitate payment, submit copy to COCOLIFE within 30 days.

COCOLIFE HealthCare Division Note:

8th Floor, Feliza Building, V.A. Rufino St., Legaspi Village, Please print 2 copies and
HEALTHCARE-079-0623-2 Makati City present it to the respective
Tel. No.: 8813-3000 | Fax No.: 8812-3363 doctor's clinic/department.