The document is an Individual Cash Claim Form from the Department of Education, which includes a Data Privacy Notice outlining the handling and protection of personal data under the Data Privacy Act of 2012. It requires employees to provide personal information, medical expense details, and necessary certifications for reimbursement claims. The form emphasizes the importance of accurate information and the consequences of submitting false claims.
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Medical - Annex B
The document is an Individual Cash Claim Form from the Department of Education, which includes a Data Privacy Notice outlining the handling and protection of personal data under the Data Privacy Act of 2012. It requires employees to provide personal information, medical expense details, and necessary certifications for reimbursement claims. The form emphasizes the importance of accurate information and the consequences of submitting false claims.
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF or read online on Scribd
Annex B
Individual Cash Claim Form
Data Privacy Notice: The Department of Education recognizes its responsibility
under the Republic Act No. 10173, otherwise known as the Data Privacy Act of 2012,
with respect to the data they collect, record, organize, update, use, consolidate or
destruct from their personnel. The personal data obtained from this form is entered
and stored within the organization's authorized information and communications
system and will only be accessed by authorized personnel, The organization has
instituted appropriate technical and physical security measures to ensure the
protection of personal data
Furthermore, the information collected and stored in the portal shall only be used
for the purposes of this activity. DepEd shall net disclose any personal information
without consent and shall retain this information over a period of ten years for the
effective implementation and management of its activities
Section 1: Employee Information
Full Name:
Employee ID Numbe
Position /Designation:
Sex: __ Date of Birth (dd/mm/yyyy):
Mobile Number:
DepEd Email Address
For teaching personnel
Employment Status: O Permanent D Contractual
O Casual 0 Substitute
Section 2: Pre-requisite Requirements.
Supported with applicable documents, check any of the following condition below
that applies.
C GIDA Certification
Oi Certification of area with no HMO
Oi Letter or email from HMO denying the application
Section 3: Details of Medical Expenses Incurred
Fame of ‘Medical | Address Datejs) of += Medical
Provider/Facility Consultation/Service
CT
Hy
he (Please add rows as necessary)
—
Deseription of Exponse ‘Amount (in PHP)
Receipt No./Reference
Consultation Fee
Laboratory /Diagnostic Tests
fo
Medication
Hospitalization
Others (please speciiy)
Total Amount
Please attach eriginal receipts
Section 3: Certification
1, the undersigned, hereby certify that the information provided in this claim form is
true and correct to the best of my knowledge, and the medical expenses listed above
were incurred for legitimate medical purposes. [ understand that submission of false
claims shall be subject ta disciplinary action and other legal consequences as
determined necessary by the Department of Education.
Employee's Signature:
Date:
He
