Maxicare Healthcare Corporation

Main Office: Maxicare Tower, 203 Salcedo Street, Legaspi Village, Makati City
Call Center Toll-Free No.: 1-800-10-5821-900 or 1-800-8-5821-900
Call Center Hotline: 582-1900 or 798-7777
SMS Inquiry: 0918-889 MAXI(6294)
Homepage: http://www.maxicare.com.ph

LOE No.: 080221-33291468

OUT-PATIENT LETTER OF AUTHORIZATION LOA No.: 37794551
Date Issued: 08/02/2021
CONSULTATION Validity Date: 08/04/2021

This is to certify that Maxicare Healthcare Corporation (MAXICARE) will pay for the coverable hospital bills and professional fees of bona fide MAXICARE member named
herein, up to the benefit limit indicated herein, with the exception of below-specified charges to be collected from the same Member by your Medical Institution prior to discharge.
The HOSPITAL shall not hold MAXICARE liable for any unpaid Member charges beyond the date of discharge and shall not be part of any reconciliation item/s on future billings.

TYPE OF CONSULTATION: Initial Follow-up Clearance

MAXICARE MEMBER INFORMATION
Name of Patient: ____________________________________________________________________________________
MARIAN JUSTINE B. ROMARATE - 1168011023821864 Sex: ________
F AGE: __________________
27
Contact Info: _______________________________________________________________________________________
09973548337 - maryanjastin@gmail.com Plan: ___________________________________
0010054645000004-PLA-C01136-20-P
Company: _________________________________________________________________________________________
C01136-ACCENTURE BPO MAXICARE Policy No.: ____________________
140127305400
Attending Doctor: ___________________________________________________________________________________
SUAREZ, MARIA NANETTE GO Effectivity / Expiry: _______________________
09/01/2020 - 08/31/2021
Clinic/Hospital Name: ________________________________________________________________________________
CUPSI CENTER FOR WOMEN'S HEALTH INC. Date of Availment: ________________________
08/02/2021
Referring Doctor: ___________________________________________________________________________________ PHIC: Required Not Required

INSTRUCTION
1. For validation purposes, this document must be signed by the member / guardian of minor members.
2. The attending physician / service provider must fill up and sign the portion provided.
3. For claims processing, the duly accomplished document together with the Statement of Account (SOA) must be submitted to Maxicare Healthcare Corporation
(MAXICARE) office within the agreed period. Late filings will take longer to process and claims filed beyond forty five (45) days shall not be processed at all. Incomplete
forms and documentation will be returned to the provider.
4. FOR STRICT COMPLIANCE OF THE MD: Please indicate the PERTINENT chief complaint, history of present illness, past medical or family history, physical
examination findings, and diagnosis on the boxes provided below. For availments and procedures requested for the purpose of ruling out a disease entity, please
ALWAYS indicate your PRIMARY DIAGNOSIS. RULE OUT <disease> WILL NOT BE ACCEPTED.
(I) C H I E F C O M P L A I N T (II) H I S T O R Y O F P R E S E N T I L L N E S S
Consult

(III) P A S T M E D I C A L / F A M I L Y HISTORY (IV) P H Y S I C A L E X A M I N A T I O N FINDINGS

(V) D I A G N O S I S (VI) L A B O R A T O R Y / A N C I L L A R Y P R O C E D U R E S

THE FOLLOWING HOSPITAL CHARGES SHOULD BE COLLECTED BY THE MEDICAL INSTITUTION FROM THE PATIENT DURING DISCHARGE
Prosthetic device, corrective appliances and artificial devices
Co-payment arrangement: % (Percentage) of the total charges (HB + PF): _________________________ Amount: _________________________
Others: ________________________________________________________________________________________________________________

Attending Physician: Prepared By:

____________________________________________
Signature Over Printed Name
THIS IS ELECTRONICALLY GENERATED, NO SIGNATURE REQUIRED

CONFORME
I agree that any availment may be denied by MAXICARE HEALTHCARE In connection with the foregoing, I here by irrevocably authorize MAXICARE, being my
CORPORATION (MAXICARE) under the following circumstances: healthcare maintenance services provider, as my attorney-infact to:
1. Concealment, whether intentional or not, of relevant medical information whether
related to the current availment or not. (1) Examine and obtain copies of my and/or dependents' medical records as well
2. Treatment or Procedures not related to the illness for which this document was as any information relating to my (and/or my dependents') hospitalization,
issued as determined by the MAXICARE. consultation, treatment or any other medical advice from whatever source
as a condition to my (and/or my dependents') availment of any benefits under
Futher, MAXICARE is not responsible for the payment of charges/expenses resulting the Service Agreement; and (b) disclose such information to Maxicare, and/or
from: its duly authorized representative/s, sub-contractors and/or brokers, if
1. Availment of the following hospital or medical services/treatment/procedures necessary, and my employer and/or its authorized representatives, upon
(diagnostic and therapeutic): (i) those rendered by Non-affiliated Physicians/ request. In lieu of the original record, a certified photocopy will be honored
Specialists and/or a Non-affiliated Reliever Physician; (ii) those not related as the original.
to this confinement as determined by MAXICARE; (iii) those without prior
authorization of MAXICARE; (iv) those miscellaneous items outside of the For purposes hereof, I hereby warrant that I have been duly authorized by
healthcare benefit plan; or (v) room accommodation beyond my benefit plan my dependent/s to sign and execute any and all documents and make
limits. representations for and in his/their behalf as if the same were personally done
2. Failure to file philhealth benefit claim to cover all Philhealth costs incurred by him/them. I further agree to hold Maxicare free and harmless from and
during my confinement. against any and all suits or claims, actions, or proceedings, damages, costs
3. Personal preference to prolong confinement beyond my Attending Physician's and expenses, including attorney's fees, which may be filed, charged or
prescribed duration of hospitalization. adjudged against Maxicare or, in connection with or arising from the
4. Amount in excess of my allowable benefit limit in the professional fee of disclosure of such information.
Attending Doctor/s with whom I have prior agreement.
5. Benefit availment found to be not covered and deemed excluded by the Service (2) Collect from me the expenses incurred relative to any availment, if upon post
Agreement executed by and between MAXICARE and the Members employer verification by MAXICARE, any of the above-mentioned circumstances be
and/or the Member (the ''Service Agreement ''), including concealment, whether found present.
intentional or not, of relevant medical information, and those in excess of my
Annual Benefit Limit (ABL) / Maximum Benefit Limit (MBL), even if conditionally
approved by MAXICARE. In thos regard, if at the time of issuance of the letter I understand that the benefits and coverage requiring the services of a physician shall
of Authority (LOA) the amount of my previous availment is not reflected yet. only be performed by an Accredited Physician or Specialist referred by MAXICARE. I
MAXICARE RESERVES THE RIGHT TO THE FINAL ADJUDICATION OF MY am aware that there is an agreed standard Professional Fee/s for specific medical
COVERAGE based on the total remaining balance of my benefit limit. services between the Physician and MAXICARE. Should I undertake a private
6. Other expenses and charges analogous to the foregoing. arrangement with the Physician or Specialist for higher Professional Fee/s, I shall be
personally liable to pay for the amount resulting from said balance billing and other
Issuer: Customer Care Effectivity Date: 1 October 2014 Form No.: FO-CC-0.004 Rev. 01 additional charges. In no case may I demand for reimbursement from MAXICARE for
the balance billing charged by the Accredited Physician or Specialist.

___________________________________________________ ______________
Signature Over Printed Name of Member, Relative, or Guardian Date Signed
If Relative, relationship to Member:_______________________
Contact No.:_________________________________________