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Letter of Authorization (LOA) : DIAGNOSTIC/ Procedure Approval Form | PDF | Medical Diagnosis | Health Sciences
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Letter of Authorization (LOA) : DIAGNOSTIC/ Procedure Approval Form

This letter of authorization certifies that the patient named, Aira Jane J. Bobadilla, is a member of CareHealth Plus Systems International, Inc. and is entitled to coverage under her plan for an annual physical exam. The letter provides approval for diagnostic tests including a medical history and exam, chest x-ray, blood tests, urinalysis, fasting blood sugar test, and ECG. It requests that all bills and supporting documents be sent to CareHealth's medical payments department along with this letter of authorization.

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Levelyn de Grano
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2K views1 page

Letter of Authorization (LOA) : DIAGNOSTIC/ Procedure Approval Form

This letter of authorization certifies that the patient named, Aira Jane J. Bobadilla, is a member of CareHealth Plus Systems International, Inc. and is entitled to coverage under her plan for an annual physical exam. The letter provides approval for diagnostic tests including a medical history and exam, chest x-ray, blood tests, urinalysis, fasting blood sugar test, and ECG. It requests that all bills and supporting documents be sent to CareHealth's medical payments department along with this letter of authorization.

Uploaded by

Levelyn de Grano
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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Letter of Authorization (LOA)

(OUT – PATIENT)

This is to certify that as of this date, below – mentioned Patient is a bonafide Member of CareHealth Plus Systems
International, Inc. He/she is entitled to the limit below under his/her plan and all necessary diagnostic and treatment,
subject to the condition/ limitations specified herein.

Hospital : GENTRI MEDICAL CENTER

DIAGNOSTIC/ procedure
APPROVAL FORM
Requested by:

Date: 1/3/2021 Priority Authorization Number:

Valid up to: 1/12/2021 HDOA100177026-01032021


Member’s Name AIRA JANE J. BOBADILLA Birthdate Age

ID Card No: GVN010000058734P Issue Date 7/27/2021


COMPANY: CAFÉ AMADEO

Chief Complaint: Past Medical History:

Diagnosis: ANNUAL PHYSICAL EXAM

Diagnostic Test/s or Procedures: Cardholder’s Signature:


✓ MEDICAL HX/EXAM
✓ CXR PA
✓ CBC
✓ U/A
✓ F/A
✓ FBS
✓ BUA
✓ ECG (30 y/o and above)
-------------------------------------------------------NOTHING FOLLOWS--------------------------------------------------------

Kindly send all Statement of Accounts and all Supporting Documents to CareHealth Plus Medical Payable Department together with
this LOA.

Prepared by: Checked by: Date&Time Prepared: __________

DULCE AMOR GREGORIO KATHERINE BENGAN, RN MSN MeHMgt Received by: ___________
Date&Time Received: __________

REMINDER: Please send the white copy CareHealth Plus Systems International Inc., Suite 905 L & S Building 1414 Roxas Blvd., Ermita
Manila. Please notify Medical Payable Department at (02) 5219927 or email us at carehealthplus@gmail.com if you do not receive
your payment within thirty (30) days from our receipt of your bills.

White: Carehealth Plus Yellow: Hospital Copy Green: Branch Copy

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