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1111111111111111111111111111111111111111111111
110910973138
 Maxlcare Healthcar~or~~~£~~~!~~n
B~~~i
Main Office: 19th Fir. Medical Plaza ~;~t~~I~oll-Free No.: 1-800-10-5821-900
Toll-Free No.: 1k-81.00-.1900-~~=~~~94call
Center Hotline: 5821-900
Corporate Trun me. .
E-mail: inquiry_customer_care@maxlcare.com.ph
Homepage: http://www.maxicare.com.ph

Out-Patient Consultation Form N~ 1457344

TYPE OF CONSULTATION: ~IAL DFOLLOW-UP DCLEA RAN CE

Doctor ID/ Name: Pr' 'Cl 9-"0 i)i;'1 2 /}:' II({~ Room No: Issued Date: \\\cq I~
Clinic/Hospital Code/Name: 41\14 t - <St-IlltlG.(-HL-1\ Issued place:
""'-~c -.n.lA'
Name of Patient ~~\ l-Vt'iA Age: 1-\-2 Sex: P Issued By: fcHJvUl~

Maxicare ID card No.: Ct>\'L';:)\. O

n.•..
'<v ~ .....
'1~~
I-I ~;--,tRlart
v~U Number: plan Code/ Name: Validity: ~'l \\ \ tD
Account Type: visit Date:
Account Name: -l-\1; ',"'f\Jo ~~'Z.?v ~~D Q;u IZN~ "CT
. . . the DIAGNOSIS box provided below. For availments and
FOR STRICT COMPLIANCE OF THE MD: Please indicate your comPllete w~~l~~ar;~~~t:~our PRIMARY DIAGNOSIS. [E.g. RIO <disease> WILL
procedures requested for the purpose of ruling out a disease entity, pease
NOT BE ACCEPTED]

DIAGNOSIS:

Bp - /66/7(b
(((. - =t-f
T- O(Q
tLr2- - ICo

RECOMMENDATION:

b-
Medical rsultant Signature
I Appro." CDd"

/ WAIVER

I agree that any availment may be denied by MAXICAREHEALTHCARECORPORATIONunder the following circumstances:
o Concealment,
not. whether intentional or not, of relevant medical information in the application of the member whether related to the current avai/ment or

o Treatment or Procedures not related to the illness for which this document was issued as determined by the Claims Department of Maxicare Healthcare
Corporation.

I also hereby authorize Maxicare Healthcare Corporation to obtain a copy of all my records relative to my hospitalization, consultation and treatment or any
other medical advice in connection with the benefit Iclaim availed under this health care agreement as deemed necessary by Maxicare Healthcare
Corporation. In lieu of the original record, a certified photocopy will be honored as the original.

REMINDERS
For validation purposes, this document must be signed by the member / guardian of minor members.

The attending physician/ service provider must fill up and sign the portion provided.

For claims processing, the dUly accomplished document together with the Statement of Account (SOA) must be submitted to Maxicare Healthcare Corporation
Office within thewill
documentation agreed period. to
be returned Late
thefilings will take longer to process and claims filed beyond six months may not be processed at all. Incomplete forms and
provider.

Signature of Member / Date

Guardian of Minor Member/Relation to Member
 .. 7
1
 My Health Clinic
SOP No: MX0000981 S
Unit 146 Shangri-La Plaza
Shaw Boulevard, Mandaluyong City Customer 10: 65126

TIN: 077-334-458-001 Customer Name: PABILONA, MARY ANN Y.

SOA Date: 11/9/2010 1:46:52PM

Class 10: Maxicare

Description Code Requesting MD Unit Price Qty Payor Amount

Maxi Consultation300 5033 DR. PANCHO ILAG 300.00 300.00

I Discount: 300.00

Patient Name:

Biller's Signature:
"- .