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Save Cert of Classification (1) For Later Certificate of
‘classification of at-risk individuals and actual charges
for SARS-CoV-2 test
e {088 8. Menem GENERAL HOSEN ®
Date
To PhitHeatth:
This is to certify that based on our records,
‘who belongs to sub-group.
Patients lastname, frst name, name extension, middle name
based on DOH DM No. 2020-0258-A, was tested for SARS-CoV-2
at JOSE B, LINGAD MEMORIAL GENERAL HOSPITAL
‘Name of Philfealth accredited SARS.CoV-2 testing laborstory/HCP
Date/s of specimen
and incurred the following charges:
alection (wend Saheveeh
Place a (v) in the appropriate tick box
1 Nocharge to patient
1 ttwith actual charges, indicate the following:
i
I
[Total actual charges
item ‘Amount (Php)
‘Amount after application of discounts/deductions (senior t =
citizen, persons with disability, guarantee letter, etc.) |
MONSERRAT S. CHICHIOCO, MD, CHA, MBA-H, FPSP, FECHA
‘Signature over printed name of the authorized testing laboratory/HCP representative
MEDICAL CENTER CHIEF IL
Designation of the authorized testing laboratory/HCP representative Date signed
Conforme:
‘Signature over printed name of the member/patient/ authorized representative Date signed
[Relationship of the representative | [J Spouse chile Cl Others,
| to member/patient 1D Siblings Parent specify
| Reason for signing on behalf of
|_ member/patient
|
the | Cy Patients incapacitated
L__© other reasons:
