SC Health and Welfare Form

Republic of the Philippines SUPREME COURT

APPLICATION FOR ASSISTANCE UNDER SUPREME COURT HEALTH AND WELFARE PLAN (Revised - 2010) (Important : Please read the attached guidelines/documents required for filling claims) The Chairperson SC Health and Welfare Plan Board

Application No. Date Received:

May I respectfully apply for Medical Assistance under the Sc Health and Welfare Plan: (check box below) Reimbursement for out-patient expenses

Reimbursement for hospitalization con nement)

Burial assistance PARTS I, II & III - TO BE ACCOMPLISHED BY MEMBER/AUTHORIZED REPRESENTATIVE PRIOR TO FILING : PART I

 Name: Position: Court/Station: Date of Assumption to Duty: Residence: Telephone/Mobile No.:  Name of Spouse (if applicable): PART II

 Name and Address of Clinic/Hospital: Attending Physician(s): Date(s) of consultation/confinement: Diagnosis: Expenses incurred: Doctor's fee (as per official receipts) Medicine(s) (only items with official receipts shall  be included)  Name and Address of Hospital/Clinic Telephone number(s) Others (specify) (only items with official receipts shall

Age: Sex: Status of Appointment:

Civil Status:

Office Telephone No.: EDP No.: Philhealth ID No.:

 be included)

TOTAL

Please read opposite page PART III III - DOCUMENTS REQUIRED CONFINEMENT

•

 Application attested by the Judge/Exec. Judge Judge or whenever appropriate Chief of Office, Office,  Administrative Services, Services, Office of the the Court Administrator ;

• • • •

Leave of Absence during confinement

•

Hospital bill receipts (o riginal) should be less MEDICARE/PHILHEALTH 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 MEDICARE/PHILHEALTH

•

Medical Certificate with signs and diagnosis Statement of Account - or iginal should be less MEDICARE/PHILHEALTH MEDICARE/PHILHEALTH Medical Prescription + receipts of medicines purchased *Note : only official receipts with clearly indicate items purchased will be honored.

Operative and Anesthesia Records - true copy should be certified by hospital authorities Doctors request/results of laboratory exams including (OR) official receipts or the examination done Hidtopathology results, if any. OUT-PATIENT

• • • • •

 Application attested by the Judge/Exec. Judge Judge or whenever appropriate Chief of Office, Office,  Administrative Services, Services, Office of the 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 (OR) official receipts or the examination done BURIAL

• • • • •

 Application attested by the Judge/Exec. Judge Judge or whenever appropriate Chief of Office, Office,  Administrative Services, Services, Office of the the Court Administrator ; Death Certificate (Certified true copy) Marriage contract (if married) Funeral Expenses  Affidavit of Guardianship Guardianship (for minor children) PLEASE TAKE NOTE : * Out-patient should be filed within 30 days from date of availment/payment of doctors fee, purchase of medicines and/or payment of laboratory fees • Medical/surgical confinement should be filed within 60 days from date of discharge. +Burial Claim should be filed within 365 days ♥ Extentention of up to 90 days may be granted if illness is dreadful.

For reference as to which illness(es) are dreadful, see attached list. ........................................ ........................................... ........................ 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  Employee, if able to sign Republic of the Philippines

)

Printed Name & Signature of Representative of employee who is unable to sign

 ______________________  ______________________

) S.S. )

SUBSCRIBED and SWORN to before me this _______ day of _____________________, 20 ____, affiant exhibiting to me his/her Supreme Court I.D. No. _______________________________ _ issued by the Supreme Court of the Philippines and signed by the afiant.

ATTY. FRIDAH LARA M. DE LEON-LUNETA Clerk of Court VI