Republic of the Philippines

SUPREME COURT

APPLICATION FOR ASSISTANCE UNDER THE SUPREME

COURT HEALTH AND WELFARE PLAN (Revised -2010)

Application No.: ___________________

The Chairperson Date Received: ____________________
SC Health and Welfare Plan Board

May I respectfully apply for Medical Assistance under the SC Health and Welfare Plan : (Check box
below)

Reimbursement for out-patient expenses Reimbursement for hospitalization

Burial Assistance (confinement)

PARTS I, II & III – TO BE ACCOMPLISHED BY MEMBER/AUTHORIZED

REPRESENTATIVE PRIOR TO FILING:

PART I
Name: _____________________________________________ Age: ___ Sex: _____ Civil Status ___________
Position : _______________________________________________ Status of Appointment: _______________
Court/Station: ______________________________________________________________________________
Date of Assumption to Duty : _________________________ Office Telephone No.: _____________________
Residence : _______________________________________________ EDP No. :________________________
Telephone/Mobile No.:_______________________________ Philhealth ID No.: ________________________
Name of Spouse (if applicable) : _______________________________________________________________

PART II
Name & Address of Clinic/Hospital: ___________________________________________________________
Attending Physician(s) : _____________________________________________________
Date(s) of consultation/confinement :___________________________________________________________
Diagnosis : ________________________________________________________________________________
Expense incurred :
Doctor’s fee
(as per official receipts)
Medicine(s)
(only items with official receipts shall be
included)
Hospitalization
(statement of account and official receipts shall
be included)
Name and Address of Hospital/Clinic
Telephone number (s)
Others(specify)
(only items with official receipts shall be
included

TOTAL

Please read the opposite page

PART III – DOCUMENTS REQUIRED
CONFINEMENT
 Application attested by the Judge/Exec. Judge or whenever appropriate Chief of Office, Administrative Services,
Office of the Court Administrator;
 Leave of absence during confinement
 Medical Certificate with signs/symptoms and diagnosis
 Statement of Account –original should be less MEDICARE/PHILHEALTH
 Medical Prescription + receipts of medicines purchased
*Note : only official receipts which clearly indicate items purchased will be honored.
 Hospital bill receipts (original) should be less MEDICARE/PHILHEALTH
*Note : Claimants whose hospital bill has been paid through private HMO, certificate of payment (original copy)
duly issued by the HMO is required.
 Professional fee receipts – original should be less MEDICARE/PHILHEALTH
 Operative and Anesthesia Records – true copy should be certified by hospital authorizes
 Doctors request/results of laboratory exams including original (OR) official receipt or the examination done
 Hispatology results, if any.

OUT-PATIENT
 Application attested by the Judge/Exec. Judge or whenever appropriate Chief of Office, Administrative Services,
Office of the Court Administrator;
 Medical Certificate with complete information – original
 Medical Prescription + receipts of medicines purchased
 Professional/consultation fee receipts
 Doctors request/results of laboratory exams including original (OR) official receipt or the examination done
BURIAL
 Application attested by the Judge/Exec. Judge or whenever appropriate Chief of Office, Administrative
Services, Office of the Court Administrator;
 Death Certificate (Certified true copy)
 Marriage Certificate (if married)
 Funeral Expenses
 Affidavit of Guardianship (for minor children)

PLEASE TAKE NOTE :

*Out-patient claims should be filed within 30 days from date of availment/payment of doctors fee,
purchase of medicines and/or payment of laboratory fees).
 Medical/surgical confinement should be filed within 60 days from date of discharge.
+ Burial Claim should be filed within 365 days
Extension of up to 90 days may be granted if illness is dreadful.
For reference as to which illness(es) are dreadful, see attached list.

I hereby certify that the information given above are true of my own knowledge. Done this ______ day
of _______________, 20 ___ at ___________________________, Philippines.

___________________________ __________________________________
Printed Name & Signature of Printed Name & Signature of Representative
Employee, if able to sign of employee who is unable to sign
Republic of the Philippines )
______________________ )S.S.
______________________ )

SUBSCRIBED and SWORN to before me this ______ day of ________________, 20_____,

affiant exhibiting to me his/her Supreme Court I.D. No. ________________________ issued by the Supreme
Court of the Philippines and signed by the affiant.
___________________________________