Application For Assistance Under The Supreme Court Health and Welfare Plan (Revised - 2010)
Application For Assistance Under The Supreme Court Health and Welfare Plan (Revised - 2010)
SUPREME COURT
May I respectfully apply for Medical Assistance under the SC Health and Welfare Plan : (Check box
below)
PART I
Name: _____________________________________________ Age: ___ Sex: _____ Civil Status ___________
Position : _______________________________________________ Status of Appointment: _______________
Court/Station: ______________________________________________________________________________
Date of Assumption to Duty : _________________________ Office Telephone No.: _____________________
Residence : _______________________________________________ EDP No. :________________________
Telephone/Mobile No.:_______________________________ Philhealth ID No.: ________________________
Name of Spouse (if applicable) : _______________________________________________________________
PART II
Name & Address of Clinic/Hospital: ___________________________________________________________
Attending Physician(s) : _____________________________________________________
Date(s) of consultation/confinement : ___________________________________________________________
Diagnosis : ________________________________________________________________________________
Expense incurred :
Doctor’s fee
(as per official receipts)
Medicine(s)
(only items with official receipts shall be
included)
Hospitalization
(statement of account and official receipts shall
be included)
Name and Address of Hospital/Clinic
Telephone number (s)
Others(specify)
(only items with official receipts shall be
included
TOTAL
Please read the opposite page
PART III – DOCUMENTS REQUIRED
CONFINEMENT
Application attested by the Judge/Exec. Judge or whenever appropriate Chief of Office, Administrative Services,
Office of the Court Administrator;
Leave of absence during confinement
Medical Certificate with signs/symptoms and diagnosis
Statement of Account –original should be less MEDICARE/PHILHEALTH
Medical Prescription + receipts of medicines purchased
*Note : only official receipts which clearly indicate items purchased will be honored.
Hospital bill receipts (original) should be less MEDICARE/PHILHEALTH
*Note : Claimants whose hospital bill has been paid through private HMO, certificate of payment (original copy)
duly issued by the HMO is required.
Professional fee receipts – original should be less MEDICARE/PHILHEALTH
Operative and Anesthesia Records – true copy should be certified by hospital authorizes
Doctors request/results of laboratory exams including original (OR) official receipt or the examination done
Hispatology results, if any.
OUT-PATIENT
Application attested by the Judge/Exec. Judge or whenever appropriate Chief of Office, Administrative Services,
Office of the Court Administrator;
Medical Certificate with complete information – original
Medical Prescription + receipts of medicines purchased
Professional/consultation fee receipts
Doctors request/results of laboratory exams including original (OR) official receipt or the examination done
BURIAL
Application attested by the Judge/Exec. Judge or whenever appropriate Chief of Office, Administrative
Services, Office of the Court Administrator;
Death Certificate (Certified true copy)
Marriage Certificate (if married)
Funeral Expenses
Affidavit of Guardianship (for minor children)
I hereby certify that the information given above are true of my own knowledge. Done this ______ day
of _______________, 20 ___ at ___________________________, Philippines.
___________________________ __________________________________
Printed Name & Signature of Printed Name & Signature of Representative
Employee, if able to sign of employee who is unable to sign
Republic of the Philippines )
______________________ )S.S.
______________________ )