The Chairperson Application No.

SC Health and Welfare Plan Board Date Received:

May I respectfully apply for Medical Assistance under the Sc Health and Welfare Plan: (check box
below)
Name: Sex: Civil Status:
Position: Status of Appointment:
Court/Station:
Date of Assumption to Duty:
Residence:
Telephone/Mobile No.: Philhealth ID No.:
Name of Spouse (if applicable):
Name and Address of Clinic/Hospital:
Attending Physician(s):
Date(s) of consultation/confinement:
Diagnosis:
Expenses incurred:
SUPREME COURT
Republic of the Philippines
EDP No.:
Office Telephone No.:
Reimbursement for out-patient expenses
Burial assistance
Age:
APPLICATION FOR ASSISTANCE UNDER SUPREME
COURT HEALTH AND WELFARE PLAN (Revised - 2010)
(Important : Please read the attached guidelines/documents required for filling claims)
Reimbursement for hospitalization
(confinement)
PARTS I, II & III - TO BE ACCOMPLISHED BY MEMBER/AUTHORIZED
REPRESENTATIVE PRIOR TO FILING :
Telephone number(s)
Others (specify)
Doctor's fee
(as per official receipts)
Medicine(s)
(only items with official receipts shall
(only items with official receipts shall
be included)
Name and Address of Hospital/Clinic
PART I
PART II
be included)
TOTAL
PART III - DOCUMENTS REQUIRED

Application attested by the Judge/Exec. Judge or whenever appropriate Chief of Office,

Administrative Services, Office of the Court Administrator ;

Leave of Absence during confinement

Medical Certificate with signs and diagnosis

Statement of Account - original should be less MEDICARE/PHILHEALTH

Medical Prescription + receipts of medicines purchased

*Note : only official receipts with clearly indicate items purchased will be honored.

Hospital bill receipts (original) should be less MEDICARE/PHILHEALTH

* Note : Claimants whose hospital bill has been paid through private HMO, certificate of payment
(original copy) duly issued by the HMO is required

Professional fee receipts - original should be less MEDICARE/PHILHEALTH

Operative and Anesthesia Records - true copy should be certified by hospital authorities
Doctors request/results of laboratory exams including (OR) official receipts or the
examination done

Hidtopathology results, if any.

Application attested by the Judge/Exec. Judge or whenever appropriate Chief of Office,

Administrative Services, Office of the Court Administrator ;

Medical Certificate with complete information - original

Medical Prescription + receipts of medicines purchased

Professional/consultation fee receipts

Doctors request/results of laboratory exams including (OR) official receipts or the

examination done

Application attested by the Judge/Exec. Judge or whenever appropriate Chief of Office,

Administrative Services, Office of the Court Administrator ;

Death Certificate (Certified true copy)

Marriage contract (if married)

Funeral Expenses

Affidavit of Guardianship (for minor children)

I hereby certify that the information given above are true of my own knowledge. Done this _____ day of
______________, 20 ___ at ________________, Philippines.
Republic of the Philippines )
CONFINEMENT
Please read opposite page
OUT-PATIENT
BURIAL
Medical/surgical confinement should be filed within 60 days from date of discharge.
+Burial Claim should be filed within 365 days
PLEASE TAKE NOTE :
* Out-patient should be filed within 30 days from date of availment/payment
of doctors fee, purchase of medicines and/or payment of laboratory fees
Employee, if able to sign
Printed Name & Signature of Representative
of employee who is unable to sign
Extentention of up to 90 days may be granted if illness is dreadful.
For reference as to which illness(es) are dreadful, see attached list.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Printed Name & Signature of
______________________ ) S.S.
______________________ )
SUBSCRIBED and SWORN to before me this _______ day of _____________________, 20 ____,
affiant exhibiting to me his/her Supreme Court I.D. No. ________________________________ issued by the
Supreme Court of the Philippines and signed by the afiant.
Clerk of Court VI
ATTY. FRIDAH LARA M. DE LEON-LUNETA