ABRAR-MADALE 71615

Republic of the Philippines PHILIPPINE HEALTH INSURANCE CORPORATION Citystate Centre Building, 709 Shaw Boulevard, Pasig City Healthline: 441-7444 Website: www.philhealth.gov.ph Date & Time of Generation : JULY 16, 2015 02:07:36 HCI Portal Reference No. : BEF100000004935604 _________________________________________________________________________________ HEALTH CARE INSTITUTION (HCI) INFORMATION Name of Institution : DITSA-AN RAMAIN RHU Accreditation No. : M14013518 _________________________________________________________________________________ MEMBER INFORMATION PhilHealth Identification No. : 230031704257 Name of Member : ABRAR , TAMMY BANDERA Sex : MALE Date of Birth : JANUARY 12, 1975 Member Category : INDIGENT _________________________________________________________________________________ PATIENT INFORMATION Name of Patient : MADALE , MONALYNDAO MANGOTARA Date Admitted : MAY 29, 2015 Date Discharged : MAY 30, 2015 Sex : FEMALE Date of Birth : SEPTEMBER 03, 1976 _________________________________________________________________________________ ELIGIBILITY INFORMATION ELIGIBLE TO AVAIL PHILHEALTH BENEFITS? = YES Reason/s: undefined _________________________________________________________________________________ Attached Documents: N/A _________________________________________________________________________________ Important Reminders: 1. Generation and printing of this form is FREE for all PhilHealth Beneficiaries. 2. This form shall be submitted along with the required PhilHealth claims forms and is valid only for the confinement/admission stated above. 3. This does not include eligibility to the rule of SINGLE PERIOD OF CONFINEMENT(SPC). It shall be established when the claim is processed by PhilHealth. Non-qualification to the rule on SPCshall result to denial of this claim. _________________________________________________________________________________

ABRAR-MADALE 71615

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