A Subsidiary of The Insular Lif e Assurance Company, Ltd.

REQUEST FOR DIAGNOSTIC WORK-UP

TO : Davao Doctors Hospital Barbaso, Noelle Krisha Dagpin 10/11/1993 / 30 / F
Name of Hospital/Lab Patient's Name Birthdate/Age/Sex
FROM : ESTUART, DARLEEN 00262667 09/23/2024
Requesting Phy sician Membership Card No. Expiration Date

DIAGNOSIS: PELVIC ENDOMETRIOSIS

Examination Desired: PHIC Required PHIC Optional

TRS W/PELVIC UTERUS AND ADNEXAL UTZ - EST AMOUNT:
5000 | NOTE: CALL FOR ADJUSTMENT IF IT EXCEEDS THE
APPROVED AMOUNT
Remarks / Endorsements :
Notice: A FINAL SOA EXCEEDING THE AMOUNT REFLECTED IN
THIS LOA CAN RESULT POSSIBLE DENIAL OF PAYMENT
AND/OR DELAYS IN PROCESSING DUE TO ADDITIONAL LEVELS
OF AUDIT FRAUD, WASTE AND ABUSE. PPE AND OTHER MISC
ITEMS NOT COVERED.
Please fill up forms completely and legibly to facilitate payment. Kindly
submit within 60 days from date of availment. Thank you.

Approv al Code: 05241140126

Date Approv ed: 05/17/2024 ESTUART, DARLEEN
Valid Until: 05/21/2024 Printed Name & Signature of Requesting Phy sician

Disclaimer: Tampering of this Letter of Authority (LOA) is prohibited and is punishable by law.
"No Person shall modify, add, erase, delete, falsify or tamper with information contained in this Letter of
Authorization (LOA). Commission of any and/or all acts are punishable by law and shall render this LOA
invalid. IHC has the right to file for a criminal, administrative and other similar cases against any person
committing the said illegal acts."

2/F Insular Health Care Bldg. 167 Dela Rosa corner Legaspi Sts.,
Legaspi Village, Makati City 1229, Metroo Manila, Philippines
Tel. No. (632) 813-01-31 Toll Free 1800-10-8177857
Http://www.insularhealthcare.com.ph