Ec Medical Reimbursement Benefit Application Page 3
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4Republic of the Philippines
EC MEDICAL REIMBURSEMENT BENEFIT APPLICATION
FORM B301
PLEASE READ INSTRUCTIONS AT THE BACK BEFORE FILLING UP
Page 2
(Rev. 12/95)
PART I - PAYEE/CLAIMANT TO FILL IN ALL ITEMS
PAYEE/CLAIMANT
Initial Claim
Related/Subsequent
ADDRESS OF PAYEE
ECC ID NO.
ZIP CODE
PAYEE/CLAIMANT
ADDRESS OF PAYEE
ECC ID NO.
ZIP CODE
PAYEE/CLAIMANT
ADDRESS OF PAYEE
ECC ID NO.
ZIP CODE
PART II - HOSPITAL TO FILL IN ALL ITEMS
NAME OF HOSPITAL
ECC NUMBER
Out-patient
Confined
ADDRESS:
DATE ADMITTED
DATE DISCHARGED
CHARGES
AMOUNT CLAIMED
AMOUNT ALLOWED
A. MEDICINES
B. LABORATORY
C. X-RAY/ULTRASOUND
D. PHYSICAL THERAPY
E. HOSPITAL ROOM/ER
F. OPERATING ROOM
G. CENTRAL SUPPLIES
H. MISCELLANEOUS/OTHERS
T O T A L
I CERTIFY THAT THE SERVICES CLAIMED ARE DULY RECORDED IN THE PATIENT’S CHART AND THE INFORMATION GIVEN IN THIS FORM,
INCLUDING THE ATTACHED COPY OF THE PATIENT’S STATEMENT OF ACTUAL CHARGES, IS CORRECT.
PRINTED NAME AND SIGNATURE OF AUTHORIZED REPRESENTATIVE
POSITION
PART III - DOCTOR TO FILL IN ALL ITEMS
DIAGNOSIS
PARTS OF THE BODY AFFECTED
PROFESSIONAL FEE
APPROVED
PRINTED NAME AND SIGNATURE OF ATTENDING PHYSICIAN
ECC NUMBER
TIN
(For SSS use only)
SERVICES RENDERED
NUMBER OF VISITS
PRINTED NAME AND SIGNATURE OF SURGEON
ECC NUMBER
TIN
SERVICES RENDERED
NUMBER OF VISITS
PRINTED NAME AND SIGNATURE OF ANESTHESIOLOGIST
ECC NUMBER
TIN
SERVICES RENDERED
NUMBER OF VISITS
PART IV - AUTHORIZATION
I AUTHORIZE THE HEREIN-NAMED HOSPITAL/EMPLOYER/PHYSICIAN/PROVIDER WHO PROVIDED/PAID THE MEDICAL SERVICES,
APPLIANCES AND SUPPLIES TO FILE AN EMPLOYEES’ COMPENSATION MEDICAL EXPENSE CLAIM UNDER P.D. NO. 626 FOR PAYMENT
OF SERVICES RENDERED TO ME DURING MY TREATMENT AND THE RELEASE TO THE SSS/EC OF ANY INFORMATION NEEDED FOR
THIS OR A RELATED EC CLAIM. I AGREE TO PAY REASONABLE EXPENSES INCURRED IN EXCESS OF WHAT ARE REIMBURSABLE
UNDER EC MEDICAL SERVICES AND ANY PORTION OF THE CLAIM SUBSEQUENTLY DISALLOWED BY SSS.
(If member cannot sign/deceased)
RIGHT THUMBPRINT
PRINTED NAME AND SIGNATURE OF EMPLOYEE
(In lieu of signature)
PRINTED NAME AND SIGNATURE OF WITNESS
Internet Edition (7/2000)
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