Republic of the Philippines OFFICE OF THE PRESIDENT PHILIPPINE CHARITY SWEEPSTAKES OFFICE Quezon City

INDIVIDUAL MEDICAL ASSISTANCE PROGRAM APPLICATION FORM

CONTROL # _______________________ PETSA : __________________ _______ INILAPIT NI ____________________ DATE RECEIVED BY PCSO __________

(Sasagutan ang lahat ng patlang.)

PANGALAN NG PASYENTE ___________________ ____________________ __________________

APELYIDO PANGALAN MIDDLE NAME

TIRAHAN (Permanente)_____________________________________________________________

(Pansamantala)_____________________________________________________________

KAPANGANAKAN ____________ EDAD ____ KASARIAN________ CIVIL STATUS ______________

NATAPOS NA PAGAARAL ____________________________________________________________

HANAPBUHAY_______________ BUWANANG KITA_____________

MIYEMBRO NG PAMILYA(KASAMA SA BAHAY)

PANGALAN EDAD CIVIL STATUS

RELASYON SA

PASYENTE

NATAPOS NA

PAGAARAL

HANAPBUHAY BUWANANG KITA

KABUUANG BUWANANG KITA NG PAMILYA: (MARKAHAN NG TSEK(__) ANG NAAAYON NA INCOME BRACKET)

____ P5,000 PABABA ____ P10,001 P15,000 ____ P20,001 PATAAS ____ P5,001 P10,000 ____ P15,001 P20,000

BUWANANG GASTUSIN NG PAMILYA:

PAGKAIN : ___________ MEDIKAL : _____________ RENTA NG BAHAY : ___________ IBA PANG GASTUSIS: _____________ KURYENTE : ___________ _____________ TUBIG : ___________ _____________

PANGANGAILANGANG TULONG :

( ) GAMOT ( ) HOSPITAL BILL ( ) HEMODIALYSIS

( ) Chemo drugs Ospital_______________________ ( ) PERITONEAL DIALYSIS(CAPD) ( ) Maintenance ( ) OR medicines Discharge Date_________________ ( ) HEARING AID ( ) Antibiotics ( ) Anti-rabies

( ) IMPLANT/ PROSTHESIS / MEDICAL DEVICES ( )LABORATORY/DIAGNOSTIC PROCEDURES

( ) IBA PA (pakisulat) ____________________________________________________________

TULONG NA NATANGGAP SA PCSO __________________________________________________

HALAGA___________ KAILAN NATANGGAP___________ WALA___

Ako ay nagpapatunay na ang lahat na nailahad dito ay totoo at tama ayon sa aking kaalaman at kakayahan.

___________________________________

I.D. ( ) Pangalan at Lagda o Thumbmark ng Kliyente (Relasyon sa Pasyente)____________________

PABALAN CHRISTINA LEAH DONAYRE

B9 L22 Phase 1 Central Plain Subd., Tres de Mayo, Digos City

10/29/1963 50 Female MarriedAB ECONOMICS

Gov't Employee 38,500.00 pesos

Pedro Benedicto Pabalan

51 yo MARRIED HUSBAND AB ECONOMICS NONE NONE

Cid Benedict Pabalan 30 yo SINGLE CHILD BS NURSING NONE NONE

Uriel Pieter Pabalan 25 yo SINGLE CHILD BS NURSING NONE NONE

Tracy Bianca Pabalan 23 yo SINGLE CHILD BS NURSING NONE NONE

Vio Antonio Pabalan 13 yo SINGLE CHILD GRADE 8 NONE NONE