OFFICE OF THE VICE PRESIDENT

Medical Assistance Application Form

Processing of Applications and Interviews are done at
Ground Floor Ben-Lor Bldg., 1184 Quezon Ave., Quezon City
Contact # (02) 8-370-1714 or 8-370-1716 local 113 and 112

Pursuant to the Data Privacy Act of 2012 (Republic Act 10173), I hereby give my consent to Date of Interview
the Office of the Vice President (OVP) to process my personal information and sensitive
personal information for my application for medical assistance. I understand that the
Record No.
processing shall be limited to the purpose specified.

I understand that I can only avail of the medical assistance as provided under OVP
guidelines such as the maximum amount of P20,000.00 and only once in one year and I will
comply with these requirements.

Name of Patient FIRST NAME MIDDLE NAME LAST NAME

Date of Birth MONTH, DAY, YEAR Age Gender Contact Number

Male Female

Current Address Philhealth Number

Diagnosis Philhealth Membership

Member Others
Dialysis Center/ DOH Non-Member
Hospital’s Name
Dependent
Family Monthly Signature No Balance Billing
Income

Details of Authorized Representative

Name of Authorized FIRST NAME MIDDLE NAME LAST NAME

Representative

Relationship to Age Gender Contact Number Signature

the Patient Male Female

Evaluation TO BE FILLED UP BY OVP PERSONNEL

DENIED Recommending Approval

Due to availment of the medical assistance within one (1) year from the date of
this application
DATE OF LAST AVAILMENT: ________________________________
Invalid/Non-compliant Documents
Blacklisted due to fraud
SIGNATURE OVER PRINTED NAME
Others: ____________________________

FOR COMPLETION OF REQUIRED DOCUMENTS

Please return on: Actual Date of Return:

Details/Instructions to be placed on the checklist at the back of this form.

RECOMMENDED FOR APPROVAL

has not availed of the medical or burial assistance from OVP within one (1)
year from the date of this application
has not been blacklisted by OVP due to fraud
has submitted complete, valid and updated documentary requirements (per
checklist at the back page)

For Credit Line Requested Amount: ________________

For Fund Transfer For: _____________________________
For issuance of Guarantee Letter Recommended Amount: _____________
Remarks: _________________________
REQUIREMENTS FOR interview Original or Certified months sa araw ng interview. o LABORATORY REQUEST na
CHEMOTHERAPY, RADIATION True Copy Original or Certified True Copy pirmado ng doktor na ang petsa
OPERATION / SURGERY / ay hindi lalampas ng 6 month sa
THERAPY, BRACHY THERAPY,
TRANSPLANT REQUIREMENTS FOR MEDICINE, araw ng interview.
HOSPITAL BILL, DIALYSIS, o QUOTATION galing sa hospital o
o ESTIMATED COST NG LABORATORY, DIAGNOSTIC
IMPLANT, SURGERY and diagnostic center kung saan
OPERATION na may PROCEDURE, THERAPY:
TRANSPLANT kumpletong pangalan, pirma at
gagawin ang laboratory o
procedure, dapat pirmado ng
lisensya ng doktor. Ang petsa ay o APPLICATION FORM na nasagutan
o REFFERAL FROM HOSPITAL authorized staff ng ospital.
di lagpas sa 6 months sa araw ng ng maayos at pirmado ng pasyente
o APPLICATION FORM - na Original or Certified True Copy
interview. Original or Certified
nasagutan ng maayos at True Copy
at ng representative (if applicable). MGA PAALALA
o MEDICAL RECORDS - Original or
pirmado ng pasyente at ng o HOSPITALIZATION,
Certified True Copy ng Clinical Magpunta ang representative ng pasyente sa
representative (if applicable). CONFINED
Abstract o Medical Certificate na
o MEDICAL RECORDS - Pinakabagong BILLING takdang araw at oras ng inyong scheduled
may kumpletong pangalan, pirma at interview na dala ang kumpleto, updated at
Original or Certified True Copy STATEMENT OF ACCOUNT na
lisensya ng doktor. (Ang date ay di valid na mga requirements.
ng Clinical Abstract o Medical may pangalan at pirma ng billing
lagpas sa 6 months sa araw ng Nagpapatupad ng Cut-Off Policy sa
Certificate na may kumpletong or accounting officer. Original or
pangalan, pirma at lisensya ng Certified True Copy interview) pagtanggap ng mga Appointment Schedule
o SOCIAL CASE STUDY REPORT
doktor. (Ang date ay di lagpas sa o HOSPITALIZATION, para panatilihing maayos ang proseso para sa
6 months sa araw ng interview) (Original o Certified True Copy)
DISCHARGED mga dumating ng tama sa oras.
o SOCIAL CASE STUDY REPORT
na pirmado ng registered social
Pinakabagong BILLING worker at ang petsa ay hindi
(Original or Certified True Copy) STATEMENT OF ACCOUNT AT Kapag na deklara na walang pasok sa
lalampas ng 1 year sa araw ng
addressed to OVP o generic. PROMISSORY NOTE (Hospital tanggapan ng gobyerno, ang inyong iskedyul
interview, addressed to OVP o
Dapat ito ay pirmado ng Bill) ang due date o ay sa susunod na araw na may pasok.
generic. Ang requester at
registered social worker at ang napagkasunduan araw ng LISTAHAN NG VALID IDs
pasyente ay dapat nakalagay din
petsa ay hindi lalampas ng 1 year pagbabayad ay di lagpas sa araw (Dapat hindi expired sa araw ng interview)
sa Social Case Study Report –
sa araw ng interview, Ang ng interview. Dapat ito ay Family Composition.
requester o representative ay pirmado ng representative ng 1. Driver’s License 9. Solo Parent ID
o PHOTOCOPY NG VALID ID (front
dapat malapit na kamag anak ng pasyente, hospital accounting 2. NBI Clearance / ID 10. TIN ID
pasyente at nakalagay sa Social and back) ng pasyente at 3. Passport 11. UMID/GSIS or SSS ID
officer o credit & collection officer.
Case Study Report – Family representative. Dapat ipakita ang 4. Philhealth ID 12. Voter’s Certificatioo/ID
Original or Certified True Copy
Composition. Original ID sa araw ng interview. 5. Police Clearance / ID 13. 4Ps ID
DIALYSIS 6. PRC ID 14. Postal ID
o PHOTOCOPY NG VALID ID o DIALYSIS QUOTATION excluding 7. PWD ID 15. Company ID
(front and back) ng pasyente at the cost of dialyzer and PF na IBA PANG REQUIREMENT 8. Senior Citizen ID 16. Barangay ID
representative Dapat ipakita ang may kumpletong pangalan, pirma
Original ID at Valid sa araw ng at lisensya ng doktor. Ang petsa o MEDICINES: KUNG ANG PASYENTE AY MENOR DE EDAD:
interview. ay di lagpas sa 6 months sa araw Pinakabagong reseta na may
1. Registered Birth Certificate
2. School ID (kasalukuyan enrolled)
IBA PANG REQUIREMENTS ng interview. Original or Certified petsa, kumpletong pangalan, 3. Barangay ID
True Copy pirma at lisensya ng doktor. 4. Service Issue Card
CHEMOTHERAPY , RADIATION IMPLANT / MEDICAL DEVICE Quotation ng gamot na galing sa
THERAPY , BRACHYTHERAPY & o OFFICIAL PRICE QUOTATION botika na pirmado ng
mula sa supplier o kopya ng representative ng botika.
RADIO-IODINETHERAPY
PCSO Guaranty Letter
o TREATMENT PROTOCOL na o LABORATORY, DIAGNOSTIC
Copy of supplier quotation na
may cost breakdown na may PROCEDURE and THERAPY
aprobado ng PCSO. Ito ay dapat
kumpletong pangalan, pirma at
may kumpletong pangalan, pirma (Physical, Occupational, Speech
lisensya ng doktor. Ang date ay
ng authorized representative at and Phototherapy)
di lagpas sa 6 months sa araw ng
ang date ay di lagpas sa 6