1. No category

t.
Republic of the I'liilippina
PHILIPPINE HEALTH INSURANCE CORPORATION
(."ilvsliilc (Anne HuiI-Iiiil;. 7o>> Sh;iv\ I!,hiIcv:iiU. Pmsi- C ii\
1'HILHEA.LTH CIRCULAR
No. QOOJ.s-2013
TO
%:
SUBJECT
ALL PHILHEALTH MEMBERS, ACCREDITED AND
CONTRACTED HEALTH CARE PROVIDERS, PI-IILHliALTH
REGIONAL OFFICES AND ALL OTHERS CONCERNED
Z BENEFIT PACKAGE RATES FOR CORONARY ARTERY
BYPASS GRAFT SURGERY. SURGERY FOR TETRALOGY OF
F ALLOT, SURGERY FOR VENTRICULAR SEPTAL
DEFECT /VND CERVICAL CANCER
I.RATIONALE
Pursuant lo Pliilhealth Hoard Resolution No \(>2L) s 2012, and Philheahh Circular
N<>. 29. s. 2012, '@Govcniiii" Policies on Philhealrh Bench I Package for Case 1 \ pe
/,", I lie following are the services ;ind rates for coronary artery bypass graft surgery
(CABG), surgery tor 1'ctnilogj ol Fnllot f'l'OI1'), sui;gt:i-\ for \-ciuricuhu scptnl tlcfccr
fN'SO), :ui(.l ccL'\riCiil cancer.
The illnesses and their u>k ckissiticalion includcLl are ,is fullou-s:
1.Slandard Risk t-llcctivc Surgery for: Coronnry Artery Bypass Gi:il;t fCAlKi),
1 dial (~ori-ection of Tetralogy of l-'tillot (TC^I:), nnd Sufgcrv for \'cnti-icul,ii
Seplal Defect i.VSD);
2.Cervical Cancer Sla^e 1 u> lliP.:
1 hese condttionh wcie chosen l.insed "ii cunx-ni evidence thai (.[unlily iienlmenl
sii^niticanily me Lenses snrvi\n] rates and c]unlih ot hie. Mmeo\-er, \ ahd
infonniumn ''or these conditions is readily available.
II.RULES FOR IDENTIFIED CASE TYPE Z
A. Only newly diagnosed cases of ccrvioil cancer shall be covered under the
benefit- packa^L. l"or comnary ai-feiT b\'pass trratt sui-gery, total conecuon (>t"
!()[@ and closure ol" \'SO, onl\ those cases lhat strictly fulfill the selections
cnleria sliall be covefed,
P.. Beginning [anuan I, 2n]3, all members availing of rhc Z Benefit shall be
i"ec|i.uied :t 3-\eaf lock-in membership prior to availmcni of the benc-fii. Tluli ick-in membership dues not apply to lifetime mcmbcfs and sp< msorc-d.
C. Pie-authorization from i'hilhcnlih based cm the approved selections en terra
per specific 7. condition shall lie required prior lo nvmlmcni of services. All
rt\]uesis for prc-aulhorization shall be completely accomplished by rhe
@fe'^ MA. TERESA A OUIAOIf f
A.O. !V. Cf iioi ItLLMS lV
DatE:._._ih..l3L_cc:r?Ti"!i~D t;!;!.1 ?. copy
cnmnicud hi^pii-.il -,mJ submilled io (lie I lend <
AklnnnisL]';iti'.>n Scriiun h>r :ipprnv;il of disapproval;
D.J lie diagnosis during; prc-iuithon/ntion shnil be tht- basis tor rcimburscmcni;
E.No bnhino billing rNBlVi policy shall be applied for eligible sponsored
program members ;md [heir <-]ualiUed dependents. Negotiated lixed co-pay
shall be applied for eligible non-sponsored members and their, tjualified
dependents. In no instance shall die fixed co-pay exceed die package t':iu.-;
F.The pi.-olesMonal fees for surgery . if C.\ H(."r, l'OI1 nnd \'S1) shtill be 20",, nl"
I he jT;ickiii;e t-.ile, ilic pn >l ession.il tees t^.ii" cervic-.il cancer is 15" <> id i Itlpark^L'e rale;
G.Palienls enrolled m the '/. beneiil will be deducted a m.iximum ut tive 'Di dayfrom ihc -13 dnys aniuial benehr linui regardless "i ihe actual lenglh ot st-.u nt [he
paticiit in I lie Iiospii.il. Such deduclinns sliall be made un the curcent ye.ir and ii(>
deductions shall be made in the succeeding yen: In cases where ilu reniruning
annual benclil limn is less ihfin tive (5) days, the member shall rtninm eligible
lo avail ol" die 7, lV-neht. provided that prumiums are updnied;
II. Any complic;ilion/s arising dining ihe hospital conhiumenl for [Ik. pavlu.ular /,
condition shall be pan ol the package;
I. [ii^pitnl conlincmcntF due to ot
(_'d by thu pnmnry
condilion shnll be paid scp.imlclv;
|. All rnles are inclusive of governmcni t;i\cs;
K. Rules on pooling of professional fees for government haling shall ;ipplv,
L In c.ises wlicn the piitiunt <j\pu<_s ;in\[iirn. (.liiring llu- coui-sc of (iv.iimeni nv
i he p-,ilienl is los( lo follow up, [he p;i\ menD schedule lor the sjil-ci["ic
lte:itmenr phase shnl! still be i-elefiscJ ns long -,is die p.Uieni hns received die
scheduled iic:umeni. The runi.unin^ tfimche sliull not be |):nd.
M.niaiul:i
All mandatory and other sen ices of the specific Z conditions shall be given
M. All
according |..i the approved cbnical p.ith\v:iys, Irenlmenl pu.jlocols, clmicnl
guidelines iind'oiher sundnrds ot cnue.
III. CASE TYPE Z
A. Elective Surgery for Standard Risk Coronan Artery Bypass Graft
1. The package code is Z005 uhlch includes the Following 1CD-1U and R\ S
codes:
RVS CODES
MANAGEMENT/PROCEDURES
33533 - 335 3 i.
335":
\mi\ P>ip.i,.s Guilt Nu.ijv
2.The package rale shiill be P55U, III 111 for the entire
nurse of imUmeni.
3.Selections criteria for CAlHr
a.Signed Meml.ier 1 ''inpowLTmcnl (Ml'.] lorm
b.Age 1'1-711 yearsf- --
'r.l -^ r,
c.Si able Uimnnrv Arim Disease requiring i;,IJ'd'i\T. 1SO|,,\TI;,D
i '**li>ii:iry Arti.TY Bypass t imt't Surgery t(,AB( '.) with iiulic;i(hiii
hn^cLl on ccu'onnry mi.itoniy, symplcini seven I v, 1A Kmclion,
.in cl/or viability icsts; nun-invasivt tcsltng cnm|')]ficcl aiul
discussed with p;itic?nc
d.CuiTt'iu McJ[c;il Stnms
i. Not in severe dccompensnlfd hcnrl failure (NYK I\'j
it. Not with severe iUigiii;i (i.'CS C'l.iss lllj
lii. No oilier cafdiac/vasculiif procedures/intervenrioi-K
planned to lie i.\nnv with <n.ABCI durine il'ie iidintssion
] Nil previous cmilIiih: siu^tTv such as (.AHU, v/ilvc suriu
etc.
ii. Nn previous t museum no ins cud Lie inUTvi.ni ionsuch
snch :is
:is
coi"(in.ii"\' ;iniiinp];ist\ or stcniin^
f. ONUNi; r-!.'RC.)SCORI;, II nud/'.i- STS ^an-m- prcdid ivc of |..v.
morulitv risi: f-r'- 5" <>]
4. The nppuoved clmicnl pulhw.iy for (.' AlK.'i ^linll re fled rhe niiindiu- >i y -,iikI
other sen ices ns iik!ic;iIl\1 in flic hiblc l:ieli '\\.
OTHER SERVICES
MANDATORY SERVICES
II'll-r.p lull ICMS OX., pl.mll [ r.,,11111, W"...l
Kpin;;, N:t, K. My. (\ikiuin, H'-S. lU'N.
(.((@.Minim-, *lu-l s-i-.iy iP \. LuomIi. I2.|r:ul I :
VMilmnvil hilim.ihuT rc.'.ls ;i^ me ..I,-Ll, nm.'opci-.irivcl\ i.L pn.;rM|x-i.lt]->^l' l ;;. ailHl hiaJlial
i11 :m AIK".
: IVr,,,@!,iv .,@,,[,r p,-,,|,l,y[n:,,-. ks.
pl.mlrt I..IHH, AIM T, I' \'V \-INR, IT,S, N;,, I., \l;.
'.dcium, Ill.'N,CR-ir[in.i,-. 11' \C . 11111:1 K :i: , , I,,-.
@s-i.n iphk- ' \l'/l:iri-r.ilj. \2-k-.\J l..( (I.A1U;.
:Oi:D. ll:i:. :is uKlicalf-J
1'i.m..|..t:hivc- .innlui.tii-s il iiiilii-:il.-J (1\ aiul ..r.,]'
Tri-ainuim, ;i. ilh.Iic.huiI. >ur]i ns
3Mulmiii.,!!,, ^is iihIi.j.iu^], micIi .1., Ih'U lilo./kn
.s[;him , \CK iiilnhirci @>, AlilV AS \
3 lV-.ip,-i:unv fvalui-CI' ck-nii
Ik I )pi-i] lli-:ijl Smi.hiit iimli'i KtiKi.il :ni.-;il)t..i.i
Iiiiiiii-.1i.ih- |.si..|iir:Miv. r.nr .11 snf-i.-il U.U
h. VI'L l'i..ph'.l.iM,. wiMi rompn
'1 C.ir.li-.iL i;cli:iliilinHic.n
c
Ndnilj/iiri'ii] @@
(.1
|ilv.M,.tlK-,:,|->v
15I<.,J oIiich-
i-p:um, 1..MW II,
t nil
t!..|
;imi
., In-
M, tnniNi-nikk IV ,u m.ill.
.,,.h.
,ndn|>,, mm,,,,,@:,!,,,KI'll]]
rt;
1,1. lliHilaiuiiH- iiiIiim
ill
;,;,.@
N.u>l,p,
Im>I
hvp ..Jll.UTIIIinll.lH
, ol
-rd:
@@t[
,;vi
a
, cIi|..i-ilU-. l.icrul..^.- s
1...
@iiipii.ifl. iu-lHiliz:il].in,',virli I., t.i 2 ,iB,,nw
o>ml>m:Hii.n willi moi.jhI
6 ( >tlicl- s[x^i:ilu saviris vis iuxlU-J, such .
S. The piivim-iu lor this pnckn^L- shall be Five Hundred Fifty Thousand
pesos (P550,000) tor ilic complete course <@) c;ir<.: which ^JinJI be LM\"en in
I wo {2) liMiiclic,-^ -.1^ h>!li>ws:
MODEOF PAYMENT
I''i.
AMOUNT
PSiiD.lii'i)
i!i lr,
FILINGSCHEDl' LE
.l.ns;iln.rJisc:h,ifBrU.ni
KiTi
li
-up
ami
2-1ir ndic
(Ivn
PSCI.IIIHI
i-,ni,i"c:h-Ji.k-n-]r,il.iln.iii< 11< @Pf)|.li
P
B. Surgery for Total Cor roc lion of Tetralogy of Fallot
I. 'I he pnckfi.^..- a.dc \* Z006 which includes ih.; following ICD-l'i nnd R\'S
MANAGEMENT/PROCEDURES
CODES
2. The p.ickviiJL1 inle shall be ]Vi2l', 'KK) for llic entire course of treatment.
3 Selections cnicrin for sui^cry U>i: TOJ1'
n. Signed Member I jnp<mpmncnl (MJ:) I'orm
b.Al'.c: I m 10 \ears + 36-1 elnvs
c.2O I '.chi >c:irdiC)j^L";im :
" McG(mil's index iA(irln/]':i r.niio ) >. 1.5
@X, sci) re Pulmonary Valve A rum 1 us : Accept able 11" v.
score /USA > .I or better
@/. score peripheral PA\ : Acceptable if 1 2 or beiiei:
ii. Absence <@>( major .lorlopulmonary coll;itei:nl arteries
(MAfTAs.
J. Ifcnixliac caLlieteii/-,ilir)n / hcinodynnnuc siudy avnilnble: PA size
a<_let|ii,ile by /. score ^i aiiJnt'ds/ 1.1 SA
e. Ni) previous c.irclinc surgery (Hlalock FnusMg Sh'.nii)
1" functional ("'lass 1-11
l>. No cu-morbid lactors. such as ;iny "I the tt'
ill. Prcopcrntive seizures
iv. Ih.iin abscess
v. Stroke events
vi. Bleeding tlisorclers
vii. InfcctLvc Liidocnrdilis
viii. Dther congenital anomalies
F'Hi(nsJp\LT[-
IIP
TWb@/gr
4. The approved climcil |v.iilnv;i\s Inr TOl1' shall reflect (lie niandiiloiy and
(iihc-c sci-viri's -.is intliruk'fJ in ilic ml.ilc Lxl >\v.
MANDATORYSERVICES
1.
NjKC,i Mi!.P'l
I'n-i I1! 1.1S ( BC| latflfl
PIT Cn ,iti 1 iiIV--i @p.; ;iriv I ck-ai incv,( 1'fk-:i @anuit'nr[@ t.llMil ctlliMlHi' ropmijciiIk lit
1
-,
.il'. I1CS t I'SIII
IT. 'II
P.,si ''I1 al.
I'lllll o1 lis \ih; nt-i.p
i-apn
Rail]
OTHER SERVICES
L'l-.uivt1an In .ticsasuulnwictl
cn.iu.iami M. li
nicils.asn ill. ati-d,suchasoral2'"'
>hali,sp,Mi S mloral
J!.fll@
cipn 11 .,S:i,111.ifI tC -Mil
'-I'lllli nanl.iic\ ih, ilnndi'd,.iichas
v,ni
i-i-sasnrf.li-.l.surll
-1IJilit @ ^P^ialiv,t
\u<.; liK-l:Ufi-k @uplvr^.
pli
|
-
N^n ill. ls|\
l.dn -('
s
(Milt ila is.
IV'
IUt
:iimi i':11 '1,|
()ti1L
1
1Post
(inn
1Dlhi
mill mn C.1
,fi
1[. Bio. dsi PP
12. I'cdi (": IV
Lib:.. asmil ami- H)-|I'.l-. @m-.I,,;,
I'i-Ii- ill:Cl
.IV
1 mill :il.-.l.
.ii.ln-] n.plv. ..Msk-i'. innimmii.
1, 1; ..-Jill: IdIH
"illCll
inKlu.-.,n; ic-..lisosin
iilcl\
@iSfll
ipn.ft l,...l]Mi.pi 1
lidf
ulpinilui
1-si CLIMIl^
haL.i nitinn @v-l-t> HIMS)
5. ['he piiynicm tor rlus pnekns^c s!in 11 be Three Hundred and Twenty
.Thousand pesos (PJip 320, 000) lor rhe complete course oi cure which
shall Lie s.i\en m [wo (2) [finches .is follows:
FILING SCHEDULE
MODE OF PAYMENT
Witlim r-.il dais ., frt-r cnmpl,;ti"ii ,,f
Rt-hahillr.Hi..n Usch-isi- Sessions (3"'-4"'
C Surgery for Closure of Ventricular Scptal Defect
1. Hit p:icl;nSc ende is Z007 which includes the (olluwing ICD-IM and RYS
mils:
ICDHI
MANAGEMENT/PROCEDURES
RVSCODES
(s'-'
t:ii.Miifof\.@ilirit-uljiSqiiiilUiliOu-itlioiuailiont
pauli
Vi!,S1
2 111c p:ick;igc rare sir/ill be P2^n, (UK) for the entire CMiu>f of Lrcnimcnr.
3. Selections ctilcn.i for suit, cry for YSD:
:i. Siiiiu-J Mcnilief 1 ;.mpi)\\i iniLin (Ml-') I'nim
b.:\^v: 1 in 5 vcars + j(.4 Javs
c.2L:)-ccliuC;iL-diMLM-:iphy
l. Isohicct YSD pcnniunbranous, subnoi'tic oi sul.ipulmonic
ii. No combined shun is such :is ,iinal sepl.tl dc-k-ct oj- p.nent
duci.us iiitenosus or .itj-ioventacuhii- scpu\l defed
"JiAOir !
i.
No oilier ussocialcd C\ ID's : such as coarctalion ol ihc anrla,
(ii- model ,iil- id seven- .loilic insiithcii.-nc\. en inoj(i-;i((.' r<>
sl-\ crc puirnonic strnosi^
iv. Pulmonar\ ;iitcry pressure-: < 5(1 mmlig nv m least 2/'."'> systolic
b!....cl pivs^Lirf
v. QP (jS- > 1.5.1
d. No previous crmlmc suigei.-\- yVA R,in<Jing)
c I'unciion.il r,lnss I-II
t. No cn-moi;bkl laciors, such ;is any ot tlic* ft:
l. Prc-opLTiUlvc Si.-1/Lircs
ii. ln-.i'\n abscu.ss
in. Stroke evenrs
iv. IMfcdmt^ clisoixlcLS
v. I nf cci ivi.- emit hj;ii"l1i[is
" M" rllinillnsnnv.il :l I) II ( HIT I ;1111 I CS AIk! ' U ll C. I" ;1SM >CKl ICtl <;( Xl^LIll 1 111
-!. [he n|'|ii<>M.il clinicul paihw.ns I'm- VSD shall rolkvl ihc mundaloiA :inU
ulli.-i M-iAirus ^ i[Khi-:ilcil in ihc tnl-.lt- lx-li.\v.
MANDATORY SERVICES
1
4
(,.
'I
'' :il> C ( ['
I'l
1' 11. i_l
mi
I'l
all
,i ll.i
H^1
1>. sl- ,p l.il) .P 1 I'
\l ( |>
|'L ini ,1 1>..1
,^ ,:h
11: tin 1": I'-i Ik-~
N .ii- in l-IS i-1. 1:
1)1
Pi
H'l
()
Ml
1]
III'
in Irii i.i _@_[
1" :,l, li
n\ ."I M IT
ill: (]: n-
all I,- C"M il,Nakl.a,\k..I'l
1'I iai:inii-
OTHER SERVICES
1Poslnpi uiivi-anlihis,knulnalr,!
HMM.lvi- HHI-::lililiir.ll!
2IIllli'l11 i-ih,:r.imlitai.il,-ui.ll:ls12
1
r
\v> :lar.an-.li-i-h.,Kii-s,
l(
i @I-.
hi i ,.,,,1 il:IMs(i-svanrr.iniiin.
ii ll.,r
111
c-.il.r
mis 11. i@mi lr in il. i, i|>i..
ami
.ii- ~l ill in
111
i.'li l>
in l' 4-.i
riilinon i\cut.Mlu-nnn-ilnl,.iil-Ii,,
vninliiM i<npp"ii.iivb'ili.-.annn:.,t-114IHhii. u-Ciilll\~civ|i.,,asiHidiil.,uih
.,..P,-i!i:i in:inli-itu.n-ih-iasi-.in.
lilllilr,JoliinamiiH-.
urnijlili.iiii:il,-,ilijji.Mii
i'ii,i-,ipl-.pnl
,l..,,,l|,,..iluaS
5. The paviiKiu lor this package shall be 1'wo Hundred l-'itiy Ihousantl
pesos (Php 250, 000) tor the complete course ol" cure which shall l.n.aivun in two (2) trnnches as follows:
MODEOFPAYMENT
AMOUNT
I"1ll.llir.-ht
l'2nu,(Km
;@@@'iiiniijiit
I'^d,nun
FILINGSCHEDULE
MUlil'JI'
Wniiin(.niliiisiit'tcici.iiipkli.nl.if
KihnlnhiaiM.ilhAi'iristSissinnv(.;@@'-
r*
< .. Cervicul Cancer Chcnioiadialion with Cobalt & Biaehylheiupy (Low
Dosi-) or I'liinm-y Stilgcly for Sl;it;e IA1, IA2-1IAI
1. [he packnsy: chi.1l' is ZOOS wliicli nulujcs ihc [ollowini. ICD-lli and RYS
Ci'C [cs
MANAGEMENT/PKOCI DURES
ICD10
11
'P llli..loi!V
1I
( n .l>
1. 1 1
n7S(l
0! (. IK
It ,1 .11
\\ .. ,( >.|>:ilt
i.i,,lLT.,i,i:,l.@
@' '<> Ih.-r.,,,)..I..-.-J.,^1suit.,
F,
1,
Si t;eIAI,,nlv:
1
'@'I'liMi-.vt'.nn!@
7.-401
v.illhnu,|,|l:,tL-,,,l
s;'l5n
!@@
SI ,^cJA2-1IA!:
1,,I.,1L-,.,I[Vlvi,
lsti-,i-L,,,,m-.irli
I; ,1 .:l
Inn-Ll'.iiv.:,,ul|,.i,.,-.i.,,-lR-I'.l ,|,lin'.di-^,nphn.
1. ii
il ..I @.Mill,,UCli,l,,,i-iiil>.il|,i,i!;i.i,|,|,.
2. I'hc p;ieLi;j,u i-,iIl- si Kill Li..- IM2H. Ul If) [m(- (Ik- lmhilt course ol Ucntnu-nl.
-^HEALTH ^
Taa7Ferej3a
quiaoit,
mm MA.
TERESAa.
A@@J|
.') Sdeci ii ins cnlci in
:i. Si-ncd Ml;. l;m-ni
l.i. No pluvious lIr'ukilIil r;i| iy
c. No pL-fviui.is luilioitu'iiipv
cl No uiH-oiiiiotlftl co-nioibiU coiulifions
c. I ivntnu'iii plan from ^yiiL-colunic ono iIdlmsi
A. The :i|i|->i(.vc-J climoil p;ith\\;i\s foi (,t-n-ic:il Cancer Prinmiy Sui^cn sh:\ll
lX'ilcci ilu1 nvAinl'rHiH^1 niul o|1k-i sl-lvilcp ^s iikIk:;iil-l1 in the inblc bclosv.
OTHER SERVICES
MANDATORYSEFIVIC
Kllip!IIL!ll|lis.a'otiniiu'.M;" "IK@
)1.S c;pr.sr,,,,n
IS.l-Cll.LlHSt
k ,-||-.,liK @^.Mu.!'1/I'[I'..\W\7U.T.in
Clm.iiuh,\IKI
1
I1 (.@-.iji/j i-i.-pi..ti\liiii-.-lr:n;iii(V
UI'll
U'-itp1
TllloMI
<l r^i-v11 lSl-l-c1\1:lllilSlilji'/1\^-ll 1. lIl-1,|,,,,lll
@
s.
').
II)
; :-.in-.-lli
@!:,:!,@
:ilIi\[Ii
1
11'-^lo-0in\'in1
:.M,,iL
:i..Hl.i-alti'.iiu:;l i..n:,,i:.-Jii.ili;cs
1Pi.sin,,,@@,*.-a nbi.iinsasnul ::,ti-il
(iiu,avi.-,ni,isan ,.,al)
Inau-il
@1SiinpuilMedina
1:,,.jnlK-im-li-.
,:iill'.:ll,'in.-;,.l liM-n-.n,
,,H-l,,.ln,,,;,miik J.i:-,:SI-'.liiaii tlllKS.
-,:,pv(V*.u,p];ilin.,.,ih(,phin,,
TNfp^KK-,'..!^!}
r.ip.,1-,.,l,Wi,k-,
>ioi-pr.cui'ii-.i-.ii.,(.ic:-.Miii phK L-l
pi-,,n-ssmi!l
5. '11H- piivnu'iit for this p:ick;it2,L- slinl! be One Hundred Twenty Thousand
pesos (Php 120, 000) for the complete con use of caic which shall be
L>,i\r(.'n in l\ui (2; rnniclu's us tnllou's:
MODEOFPAVMENT
F1I .INGSCHEDU J3
is:l!U-|lllf'lliarjr Inmi
\ITfI' -Mltin-I-.ISILll-lt, t
AMOUNT
\\
1Mti-iinclic
1M00,000
2'"1tranche
P20,0110
,ll,@-,,p
ulii
,l,tll,@@!::..'I'eKif
?
I'). Ceivieal Cancer Clienioiadiation with Linear Accelerator &
BrncliylliLTiipy (High Dose)
1. The p;ick:i-c ode is Z009 which includes die inllnwiiu, ICD-IN and RA'S
MANAGEMENT/PROCEDURES
.l.iKy
ICDHI
RVSCODJ2S
575nn
I.!
(--,'-
@.!'
5752"
Cl
r.ipv
.1 Ml\H .ki.mu
"7T-U11
111 Kinill*. '-Py(M..I.v.,@@:..,rs,@:,;
"761
2 1 \\c piK-ka-i- iwu- sh:ill Ix- 1M 75, UOO [oi llic fiiiirt o>Lii:?e of trcninu'ii
@~PrtiiiKEALTH I
3. SHivci ii 'iis ceil crin
:i. Si.uiK-tJ Ml"- l;.)Lin
h is.iu prcvioii'; ch'-Miml hcinpy
c No [irc\ im.is r;iilii)i]Ki-;ipy
'^ftfor*M :!-r;:::::::::r::;i,1r:-:::::^:J:"::^::::i
H@ Van @@reP}eV"*if7 "<"' """""""'cu c-iiioidiu commioiis
Palo- .._.-@@-j^@J^CT.J-s.py 1 4 I Iil-:ippi"'-ill clinical paih',\-:n-s fur ' icmcal Gincci ''licmciiitliiilioii shnl
CVV-V^ '''V.'--. * }@--'@"@@ :"iclkcl [he
mmiLlaliirv
iithci'
in Iihc
I l\\v
m;ind;Hijrvaiul
;iik1
ulIxT:,ci\-iccs
^(.i vicesas
asindicated
iiulicnieJ In
hi;lablc
inblc below.
belt
MANDATORY SERVICES
OTHER SERVICES
H'.;-,. . u.-.iliiMiii;. S( il i I . Nl IT I . aiuih riirn.ih I..--. ,\k>. V I /I']'l ,
\.1; i,' \i .1. iinn:ii'..i-. mi;. ..Ihm ^ -1 -1 -.
I 111:1-1.!^ rlmhi> I I:, 1 I '. .i;;in;iI I rll ] .lr-.ui IJ. @> ll'.k' :llul< ulllll.ll I . 1 @,@;:
5. ( !nin-.|lHi-.i|n ,i-:, , i:-pl.uiii. i'.ii I >..pl:mn)
6 K.ulioil[is ."lint m .1. n-l< I-.1I..U
S r<i-.|.r,,vJon @ l.il.-. i.UCmiiIi plak-K-i
"I he pin nu-iii for ill is p:ickn^<_j sli;ill be One Hunched Seventy Five
'I'liousiiiitl pesos (Php 175, 000) lor rhc coniplcic course ul" cure \Uiich
sli:i!l I.k- :^ivei] in two (2) ivnnchc? :is follow-v
MOD 5or PAYMENT
AMOUNT
@@'1 :,,K-|,,
i'123.unu
.niflu
['Sn.unn
FILINGSCHEDULE
Will ,,W,(.di,v^,.,,nrlH-li,.;.t!,:k-. 1
\xii
@@vltlinul
.liMHi.,H<(I'elMee,:imJ.i,.rj
IV. OUTPATIENT LABORATORY AND DIAGNOSTICS
All pri-op/pLv-pina'i.Uiiv Inhnmunr and dm^nosiie cNnmm;tti"ns necessnry for surreal
clennince . if mnndaioiy pi-ocedmx1* wilh uHicuil fcceipls ;iik1 which m;c dnnu on an
<)Uip,illcn[ bnsis ^hiill bv i/eimbui-seiJ by the iio^piuil Kj lIk- palicnt once PhilMcvilih li;is
p:iid ilie lusi riiiiiclie p.ivnieni^ in ihe Imspiiiil.
d: -1 -to - 1-J
V.CLAIMS FILING
All chin M- sh;i|] Ik- filed hv (he i-iniirnek'd hn^piiuls in lu-lv,ill" <@!" ilu- p-.tlinn nco >rdu i;j i
the Implementing Guidelines on the Z Benefit Pnekiigv : I'hill lcilih (.noiLir -iS.
2d!2)
VI.IiFFECTlVITY
1 his ( .ircuhir sh;ill Likt1 ft It't.'t !<>r all ;ip|")n )vcd prt'-fiullioj'iznli' his st.ii'linu I i.-hru,HA 13,
2013 Tin-; sh;ill \.k published in :inv ncA'spapLT ur^ciR'nil ctrculniion .iiul dupti'Mh.xl
ilu'aiifiLT wnli ihe ( Mfiri- <|- ihc Nniimi -|] AdmimsinHivc Rf^isici-, I 'mivitsih @ >f' ihc
VII. ANNEXES
1.Piv-iiuthon-Mlmn dK-d-.llsl nnd r-i]Ucsi
:i. CAIKI
h T< H;
<:. \'.sO
il l.rn ic:;il ( Mincer
2.( Mu-cldiM h .1 iM;lllil.lli.|-\ viikI ( >llli.T SciVlCC
:i C.\W.
I). T< >!@"
c. \'Si;>
J. On loll Ciiiuxr
ukIlJ ihotrIiii.jv
@M..V!
ENRIQUE T. ONA, MD
Sei:ixi;u:\ <)l I knllli
( )IC - Pivsidcni :iik1 01\< >
!
i i ;.@
t
n.licm- ;imoinii (I'hp)
Rifublk uf tht I'hilippiiws
i.
PHILIPPINE HEALTH INSURANCE CORPORATION
PRE-AUTI-IORIZATION REQUEST
STANDARD RISK ELECTIVE CORONARY ARTERY BYPASS GRAFT SURGERY
n atkof rkquhst_
his is to ret] lie si :ippio\ ill toi provision <>f ^lt\ ices iiikIct iliu /, lieiifhi p;u L^i.l'C for
Ill
ex >Mn.r: rr. nami-: < >r iwtikn n(nami- < >!@ 11< >sn iai::
icU-i lIlL- Kl-ll].. and cumin n .us :ls ;i!^ivi il f. H :n ;nlnn-|ll of I Ik- /. IV-lK-rn l':id.:lj.'.f.
a nbb
IUl|IIL-SlL-..l I
l;,xL-i;uii\c Diivcior/ChiLTor I In-
l'i iiiu-J N:imc cv Si^nnuiix\lluiJiiH' ( ,;U\lniv:isciil.li- Sur^foii
ll'iir Phllhcnllli l:sc Onl\ i
?APPROVED
?DISAPPROVED
-S.mulmrovcH'rnmxlN.nm.llife' ^&ALTH(
I lead, IViK'fils Adminislniliim Scainn<$jfr
~wCm^KK7aU^Aon~
SU-*
MA. n-R&iA. QUIAOIT"I|
">/@ I
An
Rifuhlh' uj'the riiilippiin'*
PHILIPPINE HEALTH INSURANCE CORPORATION
'. HW.iliM l-iiiic HinlJiiiLi 70<jSIuu Hoii[u\;ihI !';ism;( ri\
Dm.
PRE-AIITHORIZATION CHECKLIST
STANDARD RISK ELECTIVE CORONARY ARTERY BYPASS GRAFT SURGERY
ncc.i ^.irNAi
\lk-;li.-i.l li\
i.)L' \ 1.1 ]@ 11: \ I H )NS
Si;il lie (. i )f( ni;ii'1, A rtcrv I )is<. ;\\'-v iCLjLiinnL1,
I@@.!,!@@(" TINT I.SOLA IT.D Cur.;ii:in Ariu\ \h\x^
CIi:ih Suiyri'v [(^Al^Cii with indication b;iscd en
n)riiii:iiv tiiiiih mii\ , swnpu>ni s^-\ < @ ri l \, LY function,
.intl/ur \'i;il.)ihi\ [l^Is. lk >ii-in\ ;im\ u U'Sin rj
c tni]-)Ictod :iiul di'-cu^sixl willi pitli^ni
(Jn.rk cunvni inedk;il sl.Hiis:
-,). NC * f in 'M.'vcrc (Jccom]K.-nsntt\l Iic.iit hultifth. N( Vl'wilh ^@vL-n.':uii!,',lii:i (C "f :S t'l:i.-,s 111)
c NC diIkt c;ii-Jr,ic./v,isciit:n|-|lMCL-LlLlLCS/inlLT\-l_Tlili)lls |ll;iniK'(.l (') l.K.1 d<MiL
with ('l.MK ! dufmt.1; llns :idnii^^ifin
i ilu'cl: P;isi I hslnrv:
:i. Nl ) prcVMUS C;ialj;iC siir^iT) M.K'h ,is ( .AiU i,
v,ilvu sn[-j_'ci-y, ctr.
1\ M(. * ]-)ix\ h)us ii:niscLi[;iiKi'jiis c.irJuc
inlen'ciiuon slicM ;is coronary nn^ioplnsiv or
5. ONJ.INK KI'KOSrciKK II ,incl/\>r S'l S scurinu
prcdlCUvr oTImw m(irt;ilil\ t;is|.; f-'@' 5" i.j
@"
I.)
Ac; N( >s IICS
TT
@=^H-^
i.
@-f:r\:
IVO> nnnr\
@{.>
iinnV iijifr.
r(.A
;111 (o n\
U\V|[ I.hiss 1and Ihi
C(i is]
inc. 1C. [H nt.I'm i.'AIU i:mj i.lisc-nssw.1
I^lt tin
ni. T| slillUS ol'ni\ K7.1I-J. ilx-mhihu
llwill
liIV.ii iiAIK;
C') Vil
ISSiil vnhn IIU'llI
,in 1!
Wl
2
II
I'JillL dui c
!',(i III 1
U.MSI will in
1VL' 1l"l1 m
(1:1 fIII
:ippl C',ltil n
A icsUc Ijv
Ait ndint Mil
ContoniR
h\I'aiiLii
Republic of the Philippines
PHILIPPINE HEALTH INSURANCE CORPORATION
Oly.Udli; Onlie Building, 709 Shaw Boulirl Pas
Healthline -141-7444 vvw.-.' philhenllli v.o-J |-I-
_D,Hc- A tin lined : _
Dale Di-;duir.LH.'J:
Nnnu >->t I lospiul
Nnnii1 of P.uicnr _
k-iillh II > Number
STANDARD RISK ELECTIVE
CORONARY ARTERY BYPASS GRAFT SURGERY (CABG)
CHECKLIST Of MANDATORY and OTHER SERVICES
MANDATORY SERVICES
Confirmed done /
Dale signed
I m>]X Mll\ C I .:\\ Jt H.J I' H\ h.-ilS
sued ,i> :
@cbi:
@rl:lk-K [ auinl
@Blood l;,pin.L'.
@Nvi
@k
@Mi;
@IBS
@1(1. IN
@*-.i-fiiuninc
@Uicsr NK.iy (I'A/latuiMlij
@i2-i.i:,\n i.<:<.;[
@Rc.rn :iir \1;
Cmlio'l^jisr
@I'loiinioINK
@1'I.i^m,! lliriinihiipl.isim lime
Mfdicm.-n:,
@1V'I.iH1...:Ut
@Slruin
@act. iniiihuo]- <@!@ arm
@A.sA
N.mu & Slimline ,.l"
@Pro ipcrinr. u Antibu n ii:
BUnl h.mk screening nn<l blond
pmducls ;ih mdicak'd
Aullmn/ril ISIcjchI H;mk
Si a IT
CABG MANDATORY & OTHER SERVICES AND TRANCHE PA1TUENT
i ,RM?iJjil;ALTH " 'I1 |
i Ms m!
\ 'SEffi? ma"iE& a. ouiaoit !.
] O.v,-;:._*I115l_ I
Republic of the Philippines
i.
PHILIPPINE HEALTH INSURANCE CORPORATION
Cilyi.UiteCciHie Buifdmri, 1
H^illlilni" 441-744-1 w yii.v ..pji'iLi^iiy.1. p. p y_ eh
l\
Open Ik-.n ISi l"^Cl.\ uii Jc-r
(..one @il.\i
( :auli n ilSCll] irSinm-on
A
K stlu-s <,],Ws[
ImniL llintc To (C>|X- :in i-CurHISill j,u:\\ a
( ll-lll.l
(j.nli
r,
L',IS[
nil \'l-(JIT
;iilui iihii
(
irili"
V I <iii-ili rId- ah Illllli in
A nli.i
i-llC; k!i:il-Kcliah
Si.i I"
OTHER SERVICES
Ciuiliiimxl Join- In
C'.niliiiliigi'st /l):ui' signed
]' II1 \ !\ !\. J- IIS. N i. k, \|m,
iji'n i.ilil.-.' \l' Ian mil, I :-Il-.i<1 I ' (.;.
-!.>].@ I.\ I ]@.!@. .!@@ inihc.iicil
n kU !m:k:Iii.i[ null ..,, i.ik.ijJ ,|npl< s
;ui .!@@ miliiiiuil
-I l'.,M,.|>n.iii\i
I. VT[ IV,|,1,..I,..|. vi iili
"iii-i" I'm muni
' '@H']'U ssiun/
Ml[|;iWI'Hls, M[!),. IH.IIHM
lu-paiin. I M\\ II, l,,ml:i|'
-iii-Ii .is l.i'-liiim I si
i I..,' ! -i
l>li<M,,,l,r,;,,,..
.1l!](l.,il j;|ilOlM'
CA1SC MANDATORY & OTHER SERVICES AND TRANCHE PA1MENT
W*S> KA. TERESA* OUI.-.OIT
Data:V /
_CERTSF(HH TKa
&
Republic of the Philippines
PHILIPPINE HEALTH INSURANCE CORPORATION
(Jlysl.-He Centie Bi.iiklin,;, 709 .".how Boulevard. Pnsip City
Hn.-iIUiline 4<11-7-1 @14 wvjvj ijhilhr-.ilUi p,p'-'.|j!i
oiIkt imdk.iu..ii^ a. mdkalol,
S.l'-ll .1, ,-|.,|ll,l')^H'l. ,llS"MII,
[iin-.i-ini.k IV ..iil. Jil.ir.iu-,
@...s..p,,-.v,,.. hI..|..ii.iiiii-. l.--...].li.-.l.
i|"<rllri1" -mm Jnpl.i.l-i.:
.liu^s i,ImI,ui,iiiiiii,' intu.h.n
.lri|V,....|....lil.,i.,i [\ I'll -I I....!.-,-! ...
Ii.|...:;l..,-,|,|, il.n.v... [Hunp
I liloiull , 1:11 MiImm ; @.].,<>]
C< INK >RMK Id l'.\ I'll-'.N I
Prinlixl N.imc ninl Si^nnlun
KJYJftifiEALTh'
i ,....'vo^hteujs/^
! ^3
! CEr"fi;-:~o "i''
CAUO MANDAiOliV ft OTHER SERVICES AND TRANCHE I'AMMEN (
3|
scli;irL>,L-:
^u-lli:_^__^
" iRepublic of the Philippines
KPHILIPPINE HEALTH INSURANCE CORPORATION
ye? CoiUiL' Binklinn. 709 Shflw Poulevsid. Pnr.ip, Lily
Mcnllhliiir- -1-1.1-7JJ'l s'nf;w pI'iU'OliHIi r.(-iv I'll
STANDARD RISK ELECTIVE
CORONARY ARTERY BYPASS GRAFT SURGERY (CABG)
\jil-Sex Thill Icnlih No
Nnnic:
@ijuRr.Mr.Nrsuu r.ki.isr
I'k-il-t Uud,
I. First Tranche Pay men t
1~c7iinplclrd I'lnlliciillh l-XlRMSi AN1.12
V (^ompk-icd /. S:uist';i<:m <n Quoin mn.iiix'
da i r. (x iMi'i.rvi'ia'j
i >.\ ri@: r'i].ia.).
Allrslol h.
i'nniud N.inic cv Si^n.iluiv
\ iiundiny I'hv'sici.in
I'nnk-d Nairn- (S: Si^n.ilun
I @.XfCLlll\ (.- nil-i.'Cl-H-/M(.(.lic;ll {'"rtlk-l tJll
(:< >Ni( >k,\]i@: in pa riKN'i
mictl N;mu- -nut N^iini uu1
! ta;'M ~s~*F?fe:
.."./].. QU1AOIT.
CABG MANDATORY & OTHER SERVICES AND TRANCHE PAYMENT
ni' Hinh
' tRepublic of the Philippines
.*"PHILIPPINE HEALTH INSURANCE CORPORATION
*l
Him 11 Mine -Ul-744.1
STANDARD RISK ELECTIVE
CORONARY ARTERY BYPASS GRAFT SURGERY (CABG)
\lv ScsI'hlll li.-.ilrli N.i
Vkhv-is: .
D;]ir wl~ .Vlmissi< >n.
Dale <>t"UHch:irjii'.
I'KANi I II-. 2 Rl MURI-iMI '.N TS CA II @'.< !KI IS I'
II. Second Tranche Payment
I. (...inpk-lfd Cmxllac Kchnb l-orm
Lr. < '< impk-u-<.l CLTliflciilcl'i 'I'D It,
ij'a n: <:( >Mi'i.r.n:i77
I n.\ii;. i-11.1 -:i~j
i c< in^ulliiln hi
Aik-sud bv:
]'i inu-d Nnnu- c\: SiL'.n;ili
Al k-iH.lnii.1, I'h1! -icmn
lYmu\l Niinii.1 & M^iiiilnixI "xl-(.-liI[\ l- nia-cHM/,\k-(.li(.-:i] ( uikr fJiic-f
'.( iNIORMK UV PATirN'l
I'rmk-il N.nnu- :iikI Skmiiiuii
U/J~~ r.i,\.-iui;i?.f.A oiilAoir j
CABG MANDATORY & OTHER SERVICES AND TRANCI IE PAYMENT
iItqmblk of the I'liilippines
wPHILIPPINE HEALTH INSURANCE CORPORATION
I L-.illlilnii1 1 I I -"4-1-1
PRE-AUTHORIZATION REQUEST
TETRALOGY OF FALLOT SURGERY
'I hi-, is If. ix-(.|lksi nppvuv.il tor pnivi^ion nt services Lindci- llic /. henciit p:i(.k;i:_i,c
i'<.< >NJP].l-:j I.'. NAM I @@.()!@@ 1WI ll'.N I Ii'NAMT. ( )l- I II >M'I I A I.]
iiihUt I lit.- Ii.-iiik :iiil1 r.injllii.ii:- :l< .l-rccil I', if n\ :illnu-n til" iIk /. lii-iu-lll r;li.k.i;j.L.
Hi''Jul I,..
IVink-d N.init. & SiLMi.iiinx
AiitnJini* lVdi-.imc Uu-JiJoum/ <. 'Pl"> t '< in^nli:iiii
Si X.I Al. SKRYIi !;. ASSKSSMKN 1
1 hi- p;iticnr lx'l"i n.'^ h > iIk' I' 'IInw m; caii.lv 'i'v:
D NliH D l'I\l-:i> CO-I'AV rlmlicitc Amounl) I'll]
,\ssr>s.
.@>srd nv :
C( INNRMKO in'
Primed Nnim iS' Si^n.ilurc
[(.hi ck \ppnipn,m- 1'm>\)
D ( h:\lr, lVp;irliiK'iil ol"IVdi:iirn. (_,irdl. il( >Ln
? Chief, Dims>f I'cdialuc 'A1 Sur^'n
Kxi'CLItlVC OliVCt'ir / ("lllL'l lit MnspUill
lor Phillu-illh L:st < )nl\ >
D M'I'Rl IVKD
D DISAPPROVED
py^'^ALTU
inn irei ,x el1 P rii HLd N: imcl
1W-. id. li I.-I1L- fits A dl nl ill slf.il mil Sci.-Hon
1).\.11
1 @-..@@"@ ma. vniLCAX ouiAqn
* iIh'pnhlk ufllm I'liiliifina
rPHILIPPINE HEALTH INSURANCE CORPORATION
@ih:,l:ik (i-nliv nuililin.9 7|][>NIi;iu l^-uffv ;mf I'.isiji C>{\
Name of I lospif-il _____
1'hill lL-nhh ID NlhtiIk-l-
PRE-AUTITORIZATION CHECKLIST
TETRALOGY OF FALLOT SURGERY
fPl.Tcc ;l An N.\>
Jl'Al
tlh\Vncndin^
Yi>
Ill :a IK
IVdiauic<aii.lio
1
V" @al If.lSl1 >..-,n-(,iti-in'..-.I
D
da\
.,-1.
->
a
N.
ln[
T:l
b.
N,
N.
i-ri)i:\@
prcvi, hiscrir<li:k-sur:ji
@i:'.cnn @nsucli-,ishIS
issmS ami)
PDA ^icnliiiL1,'>r
@l
--
ck
r i\si* :l
N,
N< Cl. nn
ull
.x;uiiii1,11ion:
>mo.i.ilvor
n
@mi.ri/xlrt'iiiiiit
N, ('( nLH'ini IChi.hik'S..ni:il
Ah itir iv.ililic
-
irall L-kcr-i
MO S| CS
1
n
@
In: ftS'.lfL ,cnl-oi'l'<>\:\\C.
(h
@
?
Yl-;
Dal,:Ik>IK-
\lU:.-.l.:dh\Alit:ndii]'_']Vxllalrn:
Cardlol,,...|--|
heck
a.
211 l/.dhH an. i<iqi;im''
\\ @it"\W iHi'icuhirSl|t|:i]1 U-K-i land
Alk'.i-il
n
wilhin1w:\ia|tp]icnll')ii
h
issccialcJCIID' s@ah
@i hci
cula
p... m<>nic v,\
l)c VetI.IVSDi
Sci
n
r.
Al Ct|LI',ltL- Pl inoniU'\;irKT\ si/e ,,r
eAn IHlluS
Ac :cPt;ib
n
d.
N.
sorMAPCA s
?
' Au-.ich OI'HCI.\].2D l.( IIOHKSL'l.TS
'$@@"
~-,jm7
in.p.n :
',Republic of the Philippines
WPHILIPPINE HEALTH INSURANCE CORPORATION
Ufalihhiic -141-7.14.1 ^w..y.[jhilhp,-HlHi p,o.- ph
TETRALOGY OF I-ALLOT - ELECTIVE TOF REPAIR
\j.r Sc:
.Uklll.SS
I'hill kvilili N..
Oak' cf liii-lh.
I I.Ik- ..f Ailinissm
lJ:ili- .il l.lisrh.iru,
i uani i ir i uriii iki ,mi;n rs n n .1 ki.ist
I. l:i(sl Tranche lJu\meiH
1.i '.>|-.\ 'il'^ompk-TfJ Ml"i-i )RM_
2.<.np\ of \pprovcj I'if -.\iillioll,-.,ill..n Ok-cUiS! A IU'i|iiist
.1 <-oniIrnul'h'. 1'iv'pur.im e I .nl>i>r,H'n\ I muiih 2Dcc!i<>
1 I :>iiviplc.ic Siu;.;iral I ipu.illw Rcpi.ri
ii. i nl mope l;ili\ t1 I I'.I'. Ktpi irl,' I niilsiln 'nicic \\ M Inn jd:i\ s [i1 i>l i >p |.\ I Inch I\l-suI
t. MAND.vn >i;>' i-i ii-;cki.isrorsi:.nvi_rr.s sk_;nij)
(>. ( .MinpleK-d / S.i11-@ E.ic-mt hi Oucsih .niKinx-SiL'.iK-d
I I i :(.mpifU\T nnd siyiK'il 1'iiilhciilih Cl-J
1).\ I !@.<.( iMJ'l.l'.'l \:.D :
I ONH >Ri\IK:
Rfl.tii' ni i< i I'aliciu:
I'.HkMl/ ( Mi.inlnn
1'nnkil N;imi.- ;nid Sii^nnunv
1 Mamiciih; Rl-yk-w c<J hv:
PHmled Name & Si^naknv
nin.iiK.u.Ti [ /, m.\n.\c;i-.r
Alk-slril In.
lVinu-d N;mu- <!v Signal
Aik-iulin^ Plnsiu.in
I'l'inrcil NhinH1 ^ Si^n.iinrc
l;.NL-aiii\L- Duvclni'/Mfilicil (Vnifi <'.hn.-f
'-@'^#AL>H
prri^i-niii^
1,l' )L-c!vriri;c.
I'.iilli.
Republic of the Philippines
t
PHILIPPINE HEALTH INSURANCE CORPORATION
OU'vUHeCfiihe Buiklnip.. 709 SIihv; BoulevFirr). P.T.igLiI^
Ho.illliliiv 4-11-7-MJ www plMlli^.Hlllij'.uv.pli
\f.<
TETRALOGY OF FALLOT - ELECTIVE TOF REPAIR
Agi-.Si-x rhillk-.illl.
N.inic: .
\dthrsl");iic of Admission: _
'R \NCI II'. 2 l;r.( H.'IRI'.MI ,N 1's Cl M'.CKI.IST
II. Second Tranche Paymeni
On-npli-lcJ l'l K:- I'l-Jiairic .:iuli:n: Rcli.ib h-rm \wlli 4 sc^i' >
2 Mcihc.il ca-iifk-nlc nl'Ol'D o> nsiilliilii >n
3. l'osh>[XTniivc 21XtIh . refill :ill,u.
i) \ rr. coMi'i.i "i i-:i">
l.( IN! i )R[\]K:
Kelniion [o I\ukt
I'nticul / C ni.iri.lnn
l\inutl N;ime ;iik! SiL'.iirin
Documuiu^ Reviewed I
PnninJ N;hik- & Sh_;nm i \i\
I'nnicit Name and Ni^naitir
Pnnk-d Nninc .iikI Siini.iinrc
@'xccum l Direct'h-/Medical denier ( 'hie
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Republic of the Philippines
PHILIPPINE HEALTH INSURANCE CORPORATION
phillip-HlUi.i'.rK'.nh
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Phil! Icitlth H; Nunibci-
TETRALOGY OF FALLOT - ELECTIVE TOF REPAIR
CHECKLIST OF MANDATORY mid OTHER SERVICES
TRANCHE I
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SERVICES1 IRSI lltANCIII^
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TETRALOGY OF TALLOl TRANCHE I
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Republic of the Philippines
PHILIPPINE HEALTH INSURANCE CORPORATION
City^tale Centre Buildim;, 709 Shaw BoliIpvskI Fasig City
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TE PRALOGY OF FALLOT TRANCHE I
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Republic o/(/](? Philippines
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PHILIPPINE HEALTH INSURANCE CORPORATION
Olv^le CcnliP Euildiiif;;. 70? Slm.v r-oiil^vjud, I'ii.iguly
PostoperativeMedications
Checkifapplicableand
placeStatus/dateorNA
a.Dopainme
j.Dobutamine
c.Nitroglycerinedrip
dMillinone
e.CalciumGlucondte
fTiamadoi
p..Midazolam(sedation]
hRaniudine
iOralUigoxm
1OralFuroseinide
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1.OralParacetamolor
ibuproTen
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11A.
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11C.
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11E.
11F.
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N;iiik- ;iih1 Si^ii.uurc <i| KxcanivL- Dirt/dor.'
Mt-dicnl Onirr ( .Inct"
TETRALOGY OF FALLOT TRANCHE I
L'lA. I
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Republic nfllw I'liilippina
PHILIPPINE HEALTH INSURANCE CORPORATION
PRE-AUTHORIZATION REQUEST
VENTRICULAR SEPTAL DEFECT (YSD) CLOSURE
n.YI'K Ol- kl'.QI iT.S'L
) re^m-sl .ippniv.il lor provision o| scp/icl;^ ihu.Icl" (Ik1 '/. Li^ncfu prn:l-,;i'.M' {@>
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A'f/wW/i1 ol the I'hilippina
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PHILIPPINE HEALTH INSURANCE CORPORATION
( "lKsUilcC culii: Huiklin-. 7|)<J Mi;n\ Huuk-wiiil \\\-\-2 ( il\
Niiinc ol" I lospilnl .
Niinu of Pniiciii
I'liill k.ilili 11') Ni
PRli-AUTHORlZATION CHECKLIST
VENTRICULAR SEl'TAL DEFECT (VSD) CLOSURE
ii'l-ici- .1 'or N.Vi
OI. U.iricW |'1( INS
,11 k:isl I \c;n
\iask-<l b\ AiicikImifj,
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Republic of the Philippines
i.
PHILIPPINE HEALTH INSURANCE CORPORATION
i ilyMnu- CoiUitj Building. 709 Sli.av Dcmlevnid. Pasif? City
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7 MANILA l( )l^' (M II X .kl.lSr OI'SI-RX'K.r.S SICiNI .1)
srTTl.lNK^AL AUSni.y.'l Si~qi_K-J 1>\ -^J_t_^n t l_i i lirijivs n_ 1: n 1 __
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CONI-ORMK
Prinkx! N.inic ;uul Siijnnmif
I )< iruiiK'Uls Review f(.l hv:
l']-inlL\l Niinu- <S: NunniuLV
PI III.I 11 Al. If I /. MANAtl
\lk-sicd l;y
I'rinU1'.! N;unc <!s; Si^nnlui
Aiifiuliin; Ph\sn:i:iii
I'nnUxl N:nm- & SkmnHUT
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Republic of the Philippines
L
PHILIPPINE HEALTH INSURANCE CORPORATION
Cily-Utc: Centre Bi.nldiiig. 709 Sliaw Boulevard. Pnr-ia City
YKN VRK.VI.AR SI .PI \l. 1)1 IT.' : T - I-J .KCTI VK VSD CI.OSL'RI
l'liill k'.ilili M,i
N.inK-: _
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Addicss
Dan- ,,r Admission
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TR.\N< I 11 @_ 2 Kl ,l.H IRKMI :N I S (.1 II .(.kl.lS !
II. Second Trundic Piiymeni
( :..ii,|ik-k'J I'l IC- Pcdi-uric ( :.,,@,hac IMv.ili |-,)im will] -I
2. Mcilicnl ciTlitlciilf <!l"( >ITJ coiisuli:
DA IK C< >MPU;.TK1>
nyri; i-"11.i@:i:>:
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kfbilli hi lit 1 ;ilk-iic
I'l inU'tl Nairn- iiiicl SitMi.ilurr
I luamiuns Rnim-J I
I'lillKxl M.inic ls; Si-jjiilluK-
pi in.! ikalti i / man.u;r,R
Aikstt'd b\
I'rinictI N;inu- ;iikI Sii>n;iUiR'
.\llcili.lill;4 Plusii:i:iM
i:\CL-Ull\-C nilfClnivMcdlCill (xMUT CIlK'K
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Republic of the Philippines
I*
PHILIPPINE HEALTH INSURANCE CORPORATION
CitysiateCt-mnj Burkintp, 709 Shnw Boulevmd, PaMECily
l-lL'.ilihlinr; .141-7-1-J'l wAw.pliillienUh.nov.pli
_]^):H-c Admit ict! : _
Dak- DisclwfK
Pliill Icillli IO Numlii
VENTRICULAR SEPTAL DEFECT
CHECKLIST OF MANDATORY ;ind OTHER SERVICES
TRANCHE I
SERVICES 1 IKS1
TRANCHE
.prune l.nl
IK. ullh pi,,
@l.n.J f,rm:i
Check nnd Indicate
Duu- Done/ Given
Attested b\:
(Name & SijriKituie of Anendiii<>
PMsiciun)
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VENTRICULAR SEI'TAL. DEFECT TRANCHE I
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L .VPHILIPPINE HEALTH INSURANCE CORPORATION
(Republic of the Philippines
nlLhhi),? .1 11-7440
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VENTRICULAR SEPTAL DEFECT TRANCHE 1
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Republic of the Philippines
PHILIPPINE HEALTH INSURANCE CORPORATION
Cilysl.ni; Centrp Building. 709 Shaw Boulevard, Pasig City
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SPosmpcuilivcJ.nbomloiy.
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9.PostoperativeMedications
'H
Checkifapplicableand
placeStatus/date01NA
a.Dopamine
b.Dobutamine
1A.
c.Nitioglycerinechip
I1C.
cl.Milrinone
11D.
e.CalciumGluconate
f.Tramadol
g.Midazolam(sedation)
h.Ranitidine
i.OralDigoxin
j.OralFurosemide
l<OralCaptopril
1.OralParacetamolor
Ibriprofen
I1E.
1F.
11G.
@MH.
t11.
1J
1K.
1L.
C( tNI'ORMT
Relation to Pnuuii
fift-nI/] ,t\u,a 1 t Iu:u\!i:in ^I Paiium
rnitcl Nniiic and Si^nnturc
Documents Reviewed b\
[],I (HAITI I /. MANAC-KU
N;imc iwhI Signiinlie mF Allendiiig PhysicinnName niul Si^iv.uuie of Kxcculivc Dntchu"/
Mcdicnl Center C.hiel"
VENTRICULAR SERIAL DEFECT TRANCHE I
_.
t" 1'nrlli
* tIte/mlilic i>l the I'liiliifines
>PHILIPPINE HEALTH INSURANCE CORPORATION
1 li-.ilililiiR- -1-11-74M \\\\u philhi-;i!lh.Lio\ pli
N.inic ciL'l losplhil
N;iiik- t if l1aurii(_
PRE-AUTIIOR.IZATION CHECKLIST
CERVICAL CANCER
i.HWI.
H :.vii<>ns
1
;.
1.
1.
ll'l iceav)
No
A1K/Slctill\AHelli.lIIIL',('\IK'()ll(.o
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Ni jlj-|:\-lniis
Mi
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led ai-mnr inl
5.
CO idldnns
I'KKI(.link-illSi:ij;iiih
Vis
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Sta^c:(i;hc<:l-;Vt.nl\"Si;i"KrTA"i
Sm.m-IA2
SeineHi|
Si:u>l-Ili2
Sli^i-HA1
Sl:iKcI1A2
Stil;;,.1114
SlMyc1IIA
SlnKc-1111)
-
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I
ti
Kepublk of the Philippines
PHILIPPINE HEALTH INSURANCE CORPORATION
(.@i!\sl;ik- (A'liliv KliiMihl!. "00 Shaw Mtuik'vmi!. I'.ism L \\\
PRE-AUTHORIZATION REQUEST FOR CERVICAL CANCER
Dutc orRt-i|ui.'si_
'Tins is to rccjUL'Si vippiuv.il loi1 prevision ot ser\ ices under ihe /, bunclii pncl^i^c
(COMPJ.KTK NAMK OFl'AriKNT)
(NAMIiOr HOSPITAL)
under ihc terms and conditions n* agreed foi- ;i\ailmcnL of the Z licnefn Package lor cervical
I lie | ia lie nl belongs lo the lollowing cal^L'/in (lid; V aj >j")to| trl;ile box).
II NUB
U FIXED CO-PAY ichemo, Inachy low elose, cball or pi-im:iry surgeiA,
0 FIXED CO-PAY (chemo. brachv high dose & linear accelerator)
Kccjui.-sti.-d by.
Nou-il l)\:
Printed Name & Signature
Printed Name & Signature
Attending Gynecologic Oncologist
Medical Director/Chief of Hospital
(l-"oi-Thill k-nllh List- Only;
LI Disapproved
Head, Benefits Administration Suction
fSiu,!i:ilLire over Primed N.imel
Hale:.
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RqnMk nfllic I'liMp/iines
PHILIPPINE HEALTH INSURANCE CORPORATION
CilWiilL1 < uilK- rtuililiny. 7t)(> Shiiw hiHikvjirJ. I'iisiu fn>
I k-Lillhlinc l-l I-7-I-II \\v\w pliiiliL-jllli.yoy.iih
_D;H<j Discharged: _
I'lull Irallli ID Number
CHECKLIST OF MANDATORY and OTHEK SERVICES
SURGERY FOR CERVICAL CANCER STAGE IA1 - II Al
TRANCHE 1
(l>l:u:u :i S and nulicalr slums 01
cl(.
r filvm]
SERVICES 1- Tranche
Check and Indicate
Physician's
Coiiionnc
Surgery (ov Cervical CA
Dale Done/ Given
Name and
(patient's
Signature
signature)
Stage IA1-IIA1
1. Pkt <peiam e 1 .aboraiory '
a. cue
h. Plnrelcl counr
c.I'jloocl (ypin^
d.Chest X-ray
c. hcc;
f. I 'RS
K. Na, K, Cl Cn
h. (.Lcaiinnit.'@ @
i. Asiy..\];r
). j'ro-rimc
k. I'nrtini Thromboplnritin
I. L 'nn;il\ sis
m. I Iistopuilit)l<my
n. Im:]g[[is:
ii. l.'lA'-lJiy,
n
n
n
n
ii
n
n
n
n
n
n
n
a.
b.
c.
d.
c
f.
li.
i.
i.
k.
I.
m.
n.
n.2. CrScnn or Mill
<). IMood suppoi-f,
o.
sctcciiing, processing
j\ ("ystoscopy
(/. l}ff >ctosiginc)ido,scnpy
"'@V/ m-MIiftlmhPrcopcmiive1 anubuitic
IVuphyl.iNi.s:
a.< .ciiiLuximc
b.CcfoNiiin
c.( )i1icj: anlJi.iiorics
n
Reimhlk nfllie Philippines
w
PHILIPPINE HEALTH INSURANCE CORPORATION
Cil>suilc (A-nlii: Ruiklnm. 7IW Xkiu Roiilo;ird. I'nsiy fii\
i
Conforme
SERVICES 1*' Tranche
Check and Indicate
Physician's
Surgery fot Cervical CA
Date Done/ Given
Name and
(patient's
Signature
signature)
Stage IA1-1IA1
3. IVoccduie done
Dare of Procedure :
For Stage IA1 alone:
Gynecologic
( )ncol<ioist :
I ^xUafascinl/Totnl
I lysferectomy with or
\\ iihoul bilakT;il
salpin^oopix Hcclt iiny
Forslngc 1A2-1B1:
R:idic;tl I lyslcrccioniy with
hdaicfal pelvic
lymphadcncctDiny, p;ir:ioi:tic
lymph node sampling
Q ltilntc-1-fll
s;ilpin^o( >ph (>it'Ct< )in\
4. lilood Ti.";"inskisJ(mi Support
(if indic:ilcJ)
?
? l;\VB DI'RBC Dl-I'l'
^. Postoperative I .nbomton
(when uuiicalcd, if done)
Check if applicable and
place date or N.\
:i (T>C with plaiclcr
h. l .< x;
c. elccirolylcs
(>. Postopemiive McJicjiruins
(;is indicnfccJ, when needed)
(..heck it applicable mid
plncu St:irns/d;tlc or N.\
:i. An:il^esics
hm
b.Antibiotics
c.l~leni:itinics
( a iinpleiutl mid Signed /,
D.
S:itisKieNoil QncsiKHiniiirc
N. ()pcr:iti\f Record
?_
Attested by:
Date:
Name and Signature of Medical Director
n i,,i-,,.,,
f Patient
! ,Republic dJ the Philippines
>'PHILIPPINE HEALTH INSURANCE CORPORATION
"lOhsUlu CoiHiL- Huililiii!.:. 7()'J Shiiu HihiIla;ii\I. I'.isili C'il>
ffy!k-:illliHin.-.|-ll-7-l-N .plnllii:;ill]ii;<.\ ph"
DnK1 Admitted:
. Dale Uischai^ci.!:
Name of l-InspiuL
'hilHealih ID Number
CHECKLIST OF MANDATORY and OTHER SERVICES
SURGERY FOR CERVICAL CANCER IA1 - II Al
TRANCHE 2
(1'hicc ;i ^ ;nul iiuliailc si;ilu^ or D;trc done (>r ( ii\cn)
Documents for 2'"' Tranche
Surgery for Cervical CA
Stage IA1-JIA1
Please check if
applicable
and indicate date
1. Ml'lIlciI (xrnlimii of ihu
oul-p:ilicnr fellow Lip
? _
coiisuliiilirin (within 2
weeks pnsi-op) wilh
written i<j<.|LK'st U>v
..ul-piiiicnt j-up smciir ">
months Mom surgery
2. [-Ii;,iop;uhol<w Kesulf
(dclnuUvi1 surgery)
?
Attested by:
Name atid Signature of Medical Director
Da(c:.
Name & Signature
of Gynecologic
Oncologist
Confonne
(Signature of
Patient)
Republic iij the I'liHi/iii'ma
PHILIPPINE HEALTH INSURANCE CORPORATION
<. iiwuto Co in c ItinWiiiji. 70') Slum Uoulewiiil. l';isiu C il>
lk;;illhlino -I4I-74-N u\\_^iilnlliojilili.in .ph
Dnlc
DiUl1 Dl^cliar^ecl: .
Phill IcmIiIi ID Number
CHECKLIST OF MANDATORY and OTHER SERVICES
CHEMOTHERAPY, BRACHYTHERAPY (LOW DOSE) WITH COBALT
CERVICAL CANCER
TRANCHE 1
(Place ;i ^ and imlKau- slarus or dale dime or oivcn)
(Clicmo,LowDoseBrachy,
CheckandIndicate
Physician'sName
DateDone/Given
&Signature
Cobalt)
Conforms
(Patient's
Signature)
1.I'rc-proccdurt.11,;il.iornl(.)r\-'
n:l.
b.Plateletcount
d.(^Iil'scK-v.w
<:.\:.('X]
i".I-I1S
b.
=
d.
c.
nr.
o.Nji,K,CI,Cn
h.<Jcntiniiie
i.AST/A],!'
jI'rotimc
ni.
\\-PailKilJliroinl)oplasfJLi
nk.
Turn1
].I'rinalysis
ni.
in.i!iMopnllioloLf\
n.
ii.l.TV-l.11/.
n.2.CTScanorM]U
o.BloodsuppoLl,
screening,processing
D
p.(\stosc>p\
H.lr...-ltj"I
D
,--&I
S-,,.i
F7^ ;.irn.,/n[ii[ii,.;,uii @,, ,-j,
Republic of the Philippines
PHILIPPINE HEALTH INSURANCE CORPORATION
C'ilWMlo I ciilic lluilding. 70') Sluiu llnulcvaiil. I'asii: fnv
I IcallMiiK -I 11 -74-1-1 u^iU'lHn.Kiillll-L-"1- v)<
SERVICES1"TRANCHE
CheckandIndicate
(Clicnio,LowDoseBiachy,
DateDone/Given
Confoinie
&Signatuie
(Patient's
Sit>uature)
Cobalt)
(ivnucolcit/ic
DatesofProcedure
Oncologist
(startmm/dd/yyendmin/dd/^):
Rndiaiion*)ncohi^isi
[f1.m\dnscHire
DatesofProcedures
Ci\nccohitJic
lnin/dLl/vy
()ncolo^isr
RadimionOncolo^isi
Cl\nccoli>i;ic
()iicolou;lsr
ni.
1ifim.licnri.-tl:iuddone
n4.
Indicatecyclenunibcf
I,II,III,IV,V,VIand
date(lnin/dd/w)
C.Supponmcdic:ili'>ns
f|1.Antiemetics
i@@'Kr
@'@@:@''"j
Iviilnoschon
Cirnnisctron
Mctoclopramldc
Q2.CI-CSI'
||3.1Icmaiiiiics
D2.
?4.C.Wilts
ra
iiliilh,-:il[li ,.,@ nh
Republic of the Philippines
PHILIPPINE HEALTH INSURANCE CORPORATION
OhsLilcCuilie I tinkling 7(10 Sl,;iv, iluulcwiiil. Piisiy l'il\
m
SERVICES1-TRANCHE
(Chemo,LowDoseBiachy,
CheckandIndicate
DateDone/Given
Physician'sName
&Signature
Cobalt)
-1.Klood'linnsfusionSupport
Confornie
(Patient's
Signature)
n
fifmdiciirvcl)
DIAVUGPKUC?I1I7
5.PostircatnicnlMcdicnlions
(homemedic;!lions,il"
indiciilcd)
;i.Amicnk'lics
b.\n;il(mjsics
ru.
c.l-k-maiinitjs
d.()iln;is
nd.
()(.iompkicdandSigned/.
S:itist:iclionOLieslionnaiic
n
7.K:idiniion'I'renlmcni
Radiation
Siiinniiin
A.1M\ic]<;idinrionfcoballj
15.I5i;iuh\thcr;ip\(low-
OncoliHusr:
na.
Db.
doSL1)
X.(^iu'moihcrnpyTrenrmcnr
SumiiKirvnndindicnicno.of
c\cicsc<implclcd
I,'||,T1UV,\\VJ(hilensr,i
compk'lcdc\clcs)
ni
Gynecologic
nii
(1n>logist:
niv
nv
nvi
Attested by:
Nnini' and Signature of Medical Director
I IDate:
'ww*\
of Paticnr
Ki'piiblic of ilit I'liilippiim
PHILIPPINE HEALTH INSURANCE CORPORATION
:i;ilc ( Vnlic Minldiiiji. 7(I1J SIkiw Jlmil^Minl. I'^ijiCih
I Iciillhline 441-7 14-1 wau plnlhculLli.L'A |>li
Name of Hospiral_
_Dafc Discharged: _
I'lull k:illh 11) Number.
CHECKLIST OF MANDATORY and OTHER SERVICES
CHEMOTHERAPY, BRACHYTHERAPY (LOW DOSE) WITH COBALT
CERVICAL. CANCER
TRANCHE 2
(1'hici.- :i ^ and indicnlr stains or Ontc tloiif < .r (.In un)
DOCUMENT 2NU
TRANCHE
Pleasecheckif
Name&
applicable
Signatureof
(Paticiu's
andindicatedate
Gynecologic
Signature)
Confomic
Oncologist
Medical Ccrtificiiie of
( )LII-l>:lticnl lollow Lip
( .on,sLih:ili<ni
f Wirhm 2 weeks nostpiocetlure) wiili wntren
ictjLiesr ti iv oui-p;irienr
pup sineiif 3 m<Hilhs postpi-f icednic
Attested by:
Niiinv anil Signature of Medical Director
Dale:
@-@iffc
En
* /Kepiihlk of the Philippines
,VPHILIPPINE HEALTH INSURANCE CORPORATION
CihsLili: f.V-nlif Building. 70') Shim Buulcniril. I'kiji Ci[>
^ll.nlihlin,' 4-11-7.144 uuu i ->llc;illhliiio
11 i 11
J-II-7U-I
il -11
MMMj.ljiilLcaUiii.lv.pli
r 11 ..ov.nh
Date Admit red: __
Date Discharged: _
I'lulHenllh ID Number
CHECKLIST OF MANDATORY and OTHER SERVICES
CHEMOTHERAPY, HIGH DOSE BRACHYTHERAPY AND
LINEAR ACCELERATOR FOR CERVICAL CANCER
TRANCHE 1
(PLiec ;i ^ niul iiulic;ilc st:ilus or Oalc done1 or C 5 i\L-n j
SEK VICES Is I TRANCHE
(Clicmorad + Linear
Check and Indicate
Con tonne
Date Done/ Given
(Patienfs
Signatnic)
Accelerator)
1. l'i;c-prucedure J ,:ibof:;Hory '
a.CMC
D @@.._.
b.l'lntulut count
n
c.Blood typing
d.Colics! X-r;iy
r
c. \:.CA]
f. l;liS
14. Nji, K, C:i, C;i
h. f Jcntininc
i. AST/ALT
j. l^roiimc
r
r
r
n
k. I'lifiiiil M lnoinhfjphisiin
h.
c.
d.
e
f.
h.
i.
j.
k.
lime
1. L' ri(in I\ sis
m. J-lisUipntholooy
n. Imping:
n.!. IX-U IV,
n
1.
in.
n
n.
n.2. Ci'Scnn or MRI
o Pilootl suj^porl",
o.
screening, processing
I"), t -vstosccjpy
lj. I'louosigmoidoscopy
n
n
@>;/mrlic<l//ltl(.m-
i.~J i,,r,,-,,,,i,i
Republic uj llw Philippines
L
PHILIPPINE HEALTH INSURANCE CORPORATION
(.'llWiite Centre tluiMiiiLL 709 Slum nnulev;inl. l';isi^ Cil>
ItL-iiltliliuc JJ I-7.U-1 unu |iliillic;illli.y<i\.pii
SERVICESlsiTRANCHE
ClicckandIndicate
(Chcmorad+Lineal
DaleDone/Given
Conforme
&Signature
Signature)
Accelerator)
2.RadiationTherapy
1.PelvicRndialion
|j1,iiK':irAccelerator
(Patient's
DatesofProcedure(
startmm/dd/vv@end
Ci\necolo^ie
mm/dd/yy):
Oncologist
2.liracluiherapv
?1li^liJ<scr;iu-
Kadiaiinn(hicolouUi
nnn/dd/vv
Crvnecol'>u;ie
(.>ncolo^isr
RadiaU<jn(.)ncoloi;isi
(i\neciIosmc
Oncologist
2.CreaLinine
ni.
3.Ms*
4.L:L'lllillvSlS
1when[ndicaicd,ifclone
1^.CJicniorlienipv
Mcdicalions
|[1('Jsplatin
n2.
ns.
Indicatecyclenimibcf
1,II,III,IV,V,VIand
date(mm/dd/yy)
r~|2.Carboplaiin
PI3.Others
("..Supportmedic'.uions'
[*~]I.Amiemetics
Ramoselron
j
(iranisetiini
Metoclopiamide
D2.G-CS1-
j|3Hcmndnics
PI4.Others
1whenindicated
h';mmliillu';illli-'
ni."
!'''"'"@/,.".@@">\'
-5-i
, ni,;n,..,i,i,
Republic of the Vhilippincs
w
PHILIPPINE HEALTH INSURANCE CORPORATION
(.'il\Nl;ik' Centre Hiiildiim. 70<> Slum H(uili;\;inl. I'u^iji C'ii\
(Chcmoiad-t-.Linear
CheckandIndicate
Physician'sName
DateDone/Given
&Signature
n
lii'indifiiinl)
D[A\;i;DI'RIU;Dl-IP
S.I'tjsiircninicniMrtlic;iti<>ns'
llvmicmcLlications,if
iiuliciiicd)
;i.AmiL-mciics
na.
h.Analgesics
c.1luiiia!mics
ne.
l\.(Mhcrs
nd.
(').C^miplcrcdandSigned/.
Saiisfaciion(^licslionn-lire
n
7.K:idi:iu<>n1Vcalnicnr
Radiation
Siimmar\'
A.VcWicRadialH.nfiincar
;Kxckialorj
()nc(jloLis(:
na.
nb.
Vi.liiacluihci/apy("hl^li
dose)"
.S.(ChemotherapyTreatment
SummiUTandindicateik.i.of
ni
nn
1,11,1iIJ\',\\\'l(a(Icasl.i
nin
niv
compleicdc\'clcsj
nv
cvclesc<impleletl
1whenindicated
Attested by:
Name and Signature of Medical Director
Dale:
(Patient's
Signature)
Accelerator)
4.l'!')i>d'[ransh-isionSuppoir
Conforme
CJvnecoloi^ic
()ncologi?r:
f 1'atierH
Republic of the Philippines
L
PHILIPPINE HEALTH INSURANCE CORPORATION
Cil>5l.ilc(Vi!Mc Biiikliii" 711') Slum ItaiiL-vml. ]'ii-iy ( il>
lle;i!llilniL--lll-7.| II n | -I i j! 11 tr.iji 11 an pli
_D:Ue Discharged: _
Name of Mos|"iial_
Phill-Ie;llh ID Number.
CHECKLIST OF MANDATORY and OTHER SERVICES
CHEMOTHERAPY, HIGH DOSE BRACHYTHERAPY WITH LINEAR
ACCELERATOR FOR CERVICAL CANCER
TRANCHE 2
(Place ;i </ and indicalc status or D:ite dune ( n- I ii\ en)
DOCUMENT2N"
TRANCHE
Pleasecheckif
applicable
Name&
CONFORMS
Signatureof
andindicatedate
Gynecologic
(Patienl's
Signature)
Oncologist
Medical(xTiificutuofOnI"1';ilicni1'<)IK)\vup
n
CoiiSLilfnlion:
(W'illiin2weekspos|
procedure)withwnllen
1'etp.iestforoiit-p:itieiH|">:ip
snie;u"3nionihsposlpi;<icedure
AlHskd by:
Name anil Signature uf Medical Direetor
%^--.w 1
-.~M.
Date:
W*i
ml i'Mlii/|>lii|||,.:,||||
@-2 iiil,winl,;il.:ilili.,m ,,|,