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    Affidavit - Incorrect Birthdate

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    Karren Cacabelos Sur
    Alejandro Manago Tapao, Sr. is submitting an affidavit to clarify his name on medical documents. He is currently hospitalized at Cagayan de Oro Polymedic General Hospital and intends to use his PHILHEALTH benefits. His PHILHEALTH claim form correctly lists his name as Alejandro Manago Tapao, Sr. However, an inpatient letter of authority from an insurance broker lists his name as just Alejandro M. Tapao. Through this affidavit, he attests that Alejandro M. Tapao on the letter and Alejandro Manago Tapao, Sr. on the claim form refer to the same person. He also states the omission of "Sr." in

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    Affidavit - Incorrect Birthdate

    Uploaded by

    Karren Cacabelos Sur
    29 views2 pages
    Alejandro Manago Tapao, Sr. is submitting an affidavit to clarify his name on medical documents. He is currently hospitalized at Cagayan de Oro Polymedic General Hospital and intends to use his PHILHEALTH benefits. His PHILHEALTH claim form correctly lists his name as Alejandro Manago Tapao, Sr. However, an inpatient letter of authority from an insurance broker lists his name as just Alejandro M. Tapao. Through this affidavit, he attests that Alejandro M. Tapao on the letter and Alejandro Manago Tapao, Sr. on the claim form refer to the same person. He also states the omission of "Sr." in

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    Alejandro Manago Tapao, Sr. is submitting an affidavit to clarify his name on medical documents. He is currently hospitalized at Cagayan de Oro Polymedic General Hospital and intends to use his PHILHEALTH benefits. His PHILHEALTH claim form correctly lists his name as Alejandro Manago Tapao, Sr. However, an inpatient letter of authority from an insurance broker lists his name as just Alejandro M. Tapao. Through this affidavit, he attests that Alejandro M. Tapao on the letter and Alejandro Manago Tapao, Sr. on the claim form refer to the same person. He also states the omission of "Sr." in

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    29 views2 pages

    Affidavit - Incorrect Birthdate

    Uploaded by

    Karren Cacabelos Sur
    Alejandro Manago Tapao, Sr. is submitting an affidavit to clarify his name on medical documents. He is currently hospitalized at Cagayan de Oro Polymedic General Hospital and intends to use his PHILHEALTH benefits. His PHILHEALTH claim form correctly lists his name as Alejandro Manago Tapao, Sr. However, an inpatient letter of authority from an insurance broker lists his name as just Alejandro M. Tapao. Through this affidavit, he attests that Alejandro M. Tapao on the letter and Alejandro Manago Tapao, Sr. on the claim form refer to the same person. He also states the omission of "Sr." in

    Copyright:

    © All Rights Reserved
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    of 2

    Republic of the Philippines }

    City of Cagayan de Oro } Ss


    x--------------------------------------------x

    AFFIDAVIT

    I, ALEJANDRO MANAGO TAPAO, SR., Filipino, married, of legal age and a resident
    of Bldg. 15-210 Katuparan Vitas, Tondo, Mla., upon my oath do hereby depose and state:
    That:

    1. I am currently confined at Cagayan de Oro Polymedic General Hospital along Velez


    St., Cagayan de Oro City.

    2. As a PHILHEALTH member, I intend to avail of PHILHEALTH’s hospitalization


    benefits during my discharge thus I have filled up Philhealth Claim Form 1 which
    indicates my true and correct name as ALEJANDRO MANAGO TAPAO, SR. A copy of
    the Philhealth claim form is herein attached as Annex “A”.

    3. In order to further defray my hospitalization expenses, I am also submitting to


    Cagayan de Oro Polymedic General Hospital and to PHILHEALTH an Inpatient Letter
    of Authority issued by Lacson & Lacson Insurance Brokers, Inc., containing a request
    to extend credit of up to Php. 300,000.00 to a certain ALEJANDRO M. TAPAO subject
    to limitations. A copy of the Inpatient Letter of Authority is herein attached as
    Annex “B”.

    4. The name ALEJANDRO M. TAPAO written on the attached Inpatient Letter of


    Authority and the name ALEJANDRO M. TAPAO, SR., written on the attached
    Philhealth Claim Form 1 refer to one and the same person.

    5. Furthermore, the name ALEJANDRO M. TAPAO specified in the Inpatient Letter of


    Authority was only an erroneous entry of my name and should properly include the
    name suffix “SR.” to read: ALEJANDRO M. TAPAO, SR.

    6. I am executing this affidavit to attest to the truth of the foregoing; to attest that I am
    the same ALEJANDRO M. TAPAO referred to in the Inpatient Letter of Authority; and,
    for whatever legal purpose it may serve.

    IN WITNESS WHEREOF, I hereunto affix my signature this March 20, 2010, City of Cagayan
    de Oro, Philippines.

    _______________________________
    ALEJANDRO M. TAPAO, SR.
    Affiant

    SUBSCRIBED AND SWORN to before me this March 20, 2010 in Cagayan de Oro
    City, affiant exhibiting to me his ______________ issued on ______________, at Cagayan de Oro
    City. I certify that I have examined Affiant and I am satisfied that he had voluntarily executed
    the foregoing Affidavit and that the contents thereof had been fully explained and
    understood by him before he affixed his signature thereon.

    Doc No. 270


    Page No. 54
    Book No. 1
    Series of 2010.

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