Medical Assistance Application Form

Please fill out the following form to submit your Medical Assistance application.

I. PERSONAL INFORMATION

Please fill out the following information.

Date of Filing^*

Membership / Employee ID Number:^*

Service:

Unit^*

First Name:^*

Middle Name:

Last Name:^*

Email Address:

II. MEDICAL CONDITION

Please provide details about the medical condition.

Medical Condition: (Please check one)^*

Dialysis Treatment

Cancer Treatment

Surgical Procedure

Work-Related Injury

Medicine & Maintenance Allowance

Date of Diagnosis / Incident / Purchase:^*

Hospital or Facility Name: (if applicable)

Amount of Medical Expenses: ₱^*

III. REQUIRED ATTACHMENTS

Submit copies along with the application form.

ATTACHMENTS:^*

Recent Medical Certificate

Valid ID of the applicant

Supporting Documents (if applicable)

IV. DECLARATION AND AGREEMENT:

Please read the following declaration carefully and tick the checkbox below.

I hereby certify that the information provided in this form is true and correct. I also understand that submitting falsified information may result in the rejection of my application and potential disciplinary action. I also agree to comply with the rules and requirements set by the PHC Employees Association - Alliance of Health Workers regarding this assistance program.^*

Date of Application:^*

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