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    Outpatient Consultation Form Letter of Guarantee (Log) : Number: 02-8895-3308 PLDT Toll Free: 1-800-10-895-3308

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    hsam.arianegracecdenaga
    The document provides a template for an outpatient consultation form letter of guarantee from a Philippine health insurance company. It includes fields for patient information, diagnosis, treatment details, and signatures from the patient, insurance company, and treating physician.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Outpatient Consultation Form Letter of Guarantee (Log) : Number: 02-8895-3308 PLDT Toll Free: 1-800-10-895-3308

    Uploaded by

    hsam.arianegracecdenaga
    67 views1 page
    The document provides a template for an outpatient consultation form letter of guarantee from a Philippine health insurance company. It includes fields for patient information, diagnosis, treatment details, and signatures from the patient, insurance company, and treating physician.

    Original Title

    10107146211308000-1

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    The document provides a template for an outpatient consultation form letter of guarantee from a Philippine health insurance company. It includes fields for patient information, diagnosis, treatment details, and signatures from the patient, insurance company, and treating physician.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    67 views1 page

    Outpatient Consultation Form Letter of Guarantee (Log) : Number: 02-8895-3308 PLDT Toll Free: 1-800-10-895-3308

    Uploaded by

    hsam.arianegracecdenaga
    The document provides a template for an outpatient consultation form letter of guarantee from a Philippine health insurance company. It includes fields for patient information, diagnosis, treatment details, and signatures from the patient, insurance company, and treating physician.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
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    MEDICAL INFORMATION CENTER (MIC)

    Number: 02-8895-3308
    PLDT Toll Free: 1-800-10-895-3308
    Email: mic@etiqa.com.ph CONTROL NO.:
    OUTPATIENT CONSULTATION FORM
    3308-24-5522753
    LETTER OF GUARANTEE (LOG)
    AVAILMENT DATE: APPROVAL CODE: APPROVED BY:
    03/02/2024 OP-2542-33706857 ETIQAPH
    HOSPITAL/CLINIC NAME: APPROVAL IS VALID UNTIL:
    ALLIED CARE EXPERTS (ACE) MALOLOS DOCTORS INC. 03/04/2024
    PATIENT NAME: AGE: GENDER:
    CALUAG, MARILYN B 62 Female
    COMPANY NAME: ID NO.: EXPIRY DATE: PLAN TYPE:
    MANILA WATER COMPANY, INC. 101-07146-211308-301 03/31/2024 MP+
    TYPE OF CONSULTATION INITIAL FOLLOW-UP CLEARANCE

    CHIEF COMPLAINT: PAST MEDICAL HISTORY:

    RECOMMENDATION:

    PERTINENT PHYSICAL FINDINGS: OTHER FINDINGS:

    FINAL DIAGNOSIS:

    TYPE OF ILLNESS: CONGENITAL MATERNITY ACQUIRED ACCIDENT

    REMARKS:
    This serves as the original LOG. For any questions, please call Medical Information Center at 02 8895-3308 or toll free 1-800-10-895-3308. Thank
    you.

    PLAN MEMBER'S PRIVACY POLICY & CONSENT: I, for myself and on behalf of my dependents, and/or my authorized representative, authorize Etiqa
    Philippines to process my personal data, such as, but not limited to, my medical diagnosis/utilization data and to disclose the said personal data to
    necessary third parties such as, but not limited to, my employer, accredited network providers, headquarter, reinsurers, group policy holders and auditors. I
    understand that the processing of my personal data shall be used in servicing my account which includes, but is not limited, to the following benefits
    administration, medical treatment, and management of the plan. I agree to receive marketing updates and offers. I agree to obtain a copy of my records
    relative to my hospitalization, consultation and treatment or any other medical advice in connection with the benefit/claim availed.
    PLAN MEMBER'S UNDERTAKING & REMINDER: Plan Member must sign AFTER availment. Unused LOG should immediately be reported to Etiqa
    Philippines Account Reconciliation Exit Clearance. Final computation of your coverage will be made once Etiqa Philippines Medical Claims Payables
    Department adjudicates your claims considering any of the following: (a) any call-less availment; (b) reimbursement claims; and (c) unprocessed claims
    that are yet to be billed by the accredited network providers. I agree that any availment may be denied under circumstances such as concealment and
    procedures not related to the illness. I agree to settle for billback any incurred ineligible excess charges on benefits. I render Etiqa Philippines free from any
    liability on the collection of the acquired excess charges on benefits.
    ACCREDITED PROVIDER'S UNDERTAKING & REMINDER:
    Accredited Network Provider must sign AFTER COMPLETION OF SERVICE. All procedures/tests must have prior approval from Etiqa Philippines MIC.
    For immediate payment, please submit all bills within 30 calendar days. Accredited Network Provider shall notify Etiqa Philippines if payment is not
    received within 30 calendar days from receipt of submitted bills.

    ETIQA PHILIPPINES
    Plan Member's Signature Over Printed Name/Date Signed LOG is auto generated and no need Physician's Signature Over Printed Name/Date Signed
    for signature

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