24/7 Customer Service Hotline: +63 (2) 8462 1800
Outside Metro Manila (toll-free for PLDT):
LETTER OF AUTHORIZATION TO PROVIDER 1-800-1888-3230
FOR CONSULTATION SERVICES
Type of Consultation m INITIAL m FOLLOW UP m CLEARANCE
OP No. : 03302273
Date Issued 11/21/2023 Valid From 11/21/2023 Valid Until 11/23/2023
Hospital / Clinic FLORIDABLANCA DOCTORS HOSPITAL INC. APPROVAL CODE
Unit / Department DR. CONRAD AVEDNEGO CARLOS 2 0 2 3 1 1 2 1 0 0 2 0 0 0 7 3
Patient Name ANGEL DOMINGO
Generated via HeyPhil
Certificate No. A0X5DG0 Age 34 Sex MALE (Signature not required)
Company Name Name & Signature of Authorized OP Coordinator / LOA Issuer
MAJOREL PHILIPPINES CORP.
Effectivity Date 05/01/2023 Expiry Date 04/30/2024
Attending Physician DR. CONRAD AVEDNEGO CARLOS Issuing Hospital / Clinic
INSTRUCTION TO PHYSICIAN For strict compliance, kindly indicate the pertinent chief complaint and daignosis/impression.
CHIEF COMPLAINT DIAGNOSIS / IMPRESSION
Sore throat REASON FOR CONSULT NOS (V65.9)
IMPORTANT For strLaboratory/Diagnostic Procedures are NOT ACCEPTABLE DR. CONRAD AVEDNEGO CARLOS
if indicated above, thus nullifies this document.
Name & Signature of Physician Date Signed
THE FOLLOWING CHARGES SHOULD BE COLLECTED FROM THE MEMBER
m Co-payment Arrangement: %(percentage) of the total charge (HB + PF) , or then amoount of .
m Others, please specify:
DECLARATION
I acknowledge that PhilCare's liability is strictly limited to the provisions of the Agreement, and it reserves the right to deny any claim or coverage that is (a)due to misrepresentation; (b)due to an exclusion; or (c)otherwise not in
conformity to the Agreement; (d)as a result of any handwritten notation or superimposition on this document. Any expenses thus incurred will be charged to me.
I hereby authorize PhilCare to receive and process any medical information that is relevant to this Letter of Authorization, in connection with the evaluation and grant of my benefits under PhilCare. A certified photocopy of this
A FRIENDLY REMINDER : Please call your
provder prior to availment service/s
Room No Name & Signature of Member, or Guardian Date Signed
Schedule
If relative, relationship to the member;
Contact No
Original Copy - Must be returned by Physician / Hospital / Clinic to PhilCare Duplicate Copy - Must be retained by Physician / Hospital / Clinic
24/7 Customer Service Hotline: +63 (2) 8462
LETTER OF AUTHORIZATION TO PROVIDER 1800
Outside Metro Manila (toll-free for PLDT):
FOR CONSULTATION SERVICES
Type of Consultation m INITIAL m FOLLOW UP m CLEARANCE OP No. : 03302273
Date Issued 11/21/2023 Valid From 11/21/2023 [Link]M
Valid Until 11/23/2023
Hospital / Clinic FLORIDABLANCA DOCTORS HOSPITAL INC. APPROVAL CODE
Unit / Department DR. CONRAD AVEDNEGO CARLOS 2 0 2 3 1 1 2 1 0 0 2 0 0 0 7 3
Patient Name
ANGEL DOMINGO Generated via HeyPhil
Certificate No. (Signature not required)
A0X5DG0 Age 34 Sex MALE
Company Name Name & Signature of Authorized OP Coordinator / LOA Issuer
MAJOREL PHILIPPINES CORP.
Effectivity Date 05/01/2023 Expiry Date 04/30/2024
Attending Physician DR. CONRAD AVEDNEGO CARLOS Issuing Hospital / Clinic
INSTRUCTION TO PHYSICIAN For strict compliance, kindly indicate the pertinent chief complaint and daignosis/impression.
CHIEF COMPLAINT DIAGNOSIS / IMPRESSION
Sore throat REASON FOR CONSULT NOS (V65.9)
IMPORTANT For strLaboratory/Diagnostic Procedures are NOT ACCEPTABLE DR. CONRAD AVEDNEGO CARLOS
if indicated above, thus nullifies this document. Name & Signature of Physician Date Signed
THE FOLLOWING CHARGES SHOULD BE COLLECTED FROM THE MEMBER
m Co-payment Arrangement: %(percentage) of the total charge (HB + PF) , or then amoount of .
m Others, please specify:
DECLARATION
I acknowledge that PhilCare's liability is strictly limited to the provisions of the Agreement, and it reserves the right to deny any claim or coverage that is (a)due to misrepresentation; (b)due to an exclusion; or (c)otherwise not in
conformity to the Agreement; (d)as a result of any handwritten notation or superimposition on this document. Any expenses thus incurred will be charged to me.
I hereby authorize PhilCare to receive and process any medical information that is relevant to this Letter of Authorization, in connection with the evaluation and grant of my benefits under PhilCare. A certified photocopy of this
A FRIENDLY REMINDER : Please call your
provder prior to availment service/s
Room No Name & Signature of Member, or Guardian Date Signed
Schedule
Contact No If relative, relationship to the member;
Original Copy - Must be returned by Physician / Hospital / Clinic to PhilCare Duplicate Copy - Must be retained by Physician / Hospital / Clinic
