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  • Imap Application Form

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    Cid Benedict Pabalan
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    This document is an application form for the Individual Medical Assistance Program of the Philippine Charity Sweepstakes Office. It contains personal information about the applicant, Christina Leah Pabalan, including her address, age, civil status, education, occupation, and monthly family income. It also lists information about her family members who live with her. The form asks about the family's monthly expenses and the specific medical needs for which assistance is being requested, including chemotherapy drugs, hospital bills, and dialysis. It requires the applicant to certify that all information provided is true and accurate to the best of her knowledge.

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    This document is an application form for the Individual Medical Assistance Program of the Philippine Charity Sweepstakes Office. It contains personal information about the applicant, Christina Leah Pabalan, including her address, age, civil status, education, occupation, and monthly family income. It also lists information about her family members who live with her. The form asks about the family's monthly expenses and the specific medical needs for which assistance is being requested, including chemotherapy drugs, hospital bills, and dialysis. It requires the applicant to certify that all information provided is true and accurate to the best of her knowledge.

    Copyright:

    © All Rights Reserved
    Scarica in formato PDF, TXT o leggi online su Scribd
    Segnala contenuti inappropriati
    10K visualizzazioni1 pagina

    Imap Application Form

    Caricato da

    Cid Benedict Pabalan
    This document is an application form for the Individual Medical Assistance Program of the Philippine Charity Sweepstakes Office. It contains personal information about the applicant, Christina Leah Pabalan, including her address, age, civil status, education, occupation, and monthly family income. It also lists information about her family members who live with her. The form asks about the family's monthly expenses and the specific medical needs for which assistance is being requested, including chemotherapy drugs, hospital bills, and dialysis. It requires the applicant to certify that all information provided is true and accurate to the best of her knowledge.

    Copyright:

    © All Rights Reserved
    Scarica in formato PDF, TXT o leggi online su Scribd
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    di 1

    Republic of the Philippines

    OFFICE OF THE PRESIDENT

    PHILIPPINE CHARITY SWEEPSTAKES OFFICE


    Quezon City

    INDIVIDUAL MEDICAL ASSISTANCE PROGRAM


    APPLICATION FORM
    CONTROL # _______________________
    PETSA : __________________ _______
    INILAPIT NI ____________________
    DATE RECEIVED BY PCSO __________
    (Sasagutan ang lahat ng patlang.)

    PABALAN
    CHRISTINA LEAH
    DONAYRE
    PANGALAN NG PASYENTE ___________________
    ____________________
    __________________
    APELYIDO

    PANGALAN

    MIDDLE NAME

    B9 L22 Phase 1 Central Plain Subd., Tres de Mayo, Digos City


    TIRAHAN (Permanente)_____________________________________________________________
    (Pansamantala)_____________________________________________________________

    50 KASARIAN________
    KAPANGANAKAN ____________
    EDAD ____
    Married
    10/29/1963
    Female CIVIL STATUS ______________

    AB ECONOMICS
    NATAPOS NA PAGAARAL ____________________________________________________________
    Gov't Employee BUWANANG KITA_____________
    HANAPBUHAY_______________
    38,500.00 pesos
    MIYEMBRO NG PAMILYA(KASAMA SA BAHAY)
    PANGALAN

    EDAD

    CIVIL
    STATUS

    RELASYON
    SA
    PASYENTE

    NATAPOS
    NA
    PAGAARAL

    HANAPBUHAY

    BUWANANG
    KITA

    Pedro Benedicto
    Pabalan
    Cid Benedict Pabalan

    51 yo

    MARRIED

    HUSBAND

    AB ECONOMICS

    NONE

    NONE

    30 yo

    SINGLE

    CHILD

    BS NURSING

    NONE

    NONE

    Uriel Pieter Pabalan

    25 yo

    SINGLE

    CHILD

    BS NURSING

    NONE

    NONE

    Tracy Bianca Pabalan

    23 yo

    SINGLE

    CHILD

    BS NURSING

    NONE

    NONE

    Vio Antonio Pabalan

    13 yo

    SINGLE

    CHILD

    GRADE 8

    NONE

    NONE

    KABUUANG BUWANANG KITA NG PAMILYA: (MARKAHAN NG TSEK(__) ANG NAAAYON NA INCOME BRACKET)

    ____ P5,000 PABABA


    ____ P5,001 P10,000

    ____ P10,001 P15,000


    ____ P15,001 P20,000

    ____ P20,001 PATAAS

    BUWANANG GASTUSIN NG PAMILYA:


    PAGKAIN
    RENTA NG BAHAY
    KURYENTE
    TUBIG

    : ___________
    : ___________
    : ___________
    : ___________

    MEDIKAL
    : _____________
    IBA PANG GASTUSIS: _____________
    _____________
    _____________

    PANGANGAILANGANG TULONG :
    ( ) GAMOT
    ( ) Chemo drugs
    ( ) Maintenance
    ( ) OR medicines
    ( ) Antibiotics
    ( ) Anti-rabies

    ( ) HOSPITAL BILL

    ( ) HEMODIALYSIS

    Ospital_______________________

    ( ) PERITONEAL DIALYSIS(CAPD)

    Discharge Date_________________

    ( ) HEARING AID

    ( ) IMPLANT/ PROSTHESIS / MEDICAL DEVICES

    ( )LABORATORY/DIAGNOSTIC PROCEDURES

    ( ) IBA PA (pakisulat) ____________________________________________________________


    TULONG NA NATANGGAP SA PCSO __________________________________________________
    HALAGA___________ KAILAN NATANGGAP___________ WALA___
    Ako ay nagpapatunay na ang lahat na nailahad dito ay totoo at tama ayon sa aking kaalaman
    at kakayahan.

    ___________________________________
    I.D. ( )

    Pangalan at Lagda o Thumbmark ng Kliyente

    (Relasyon sa Pasyente)____________________

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