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--

NOTE: Member to pay for the MISCELLANEOUS ITEMS:

Abdominal binder, additional linen, additional thermometer, anti-embolic stockings,
baby oil, bed pan, cost of electricity, telephone bills, diapers, underpads,
maternity pads, extra alcohol, extra bed, extra food/food tray, extra hospital
gown, towel, feminine napkins, feminine wash, formulated milk unless medically
necessary, hospital slippers, kidney basin, male urinals, mineral water, mouthwash,
powder, soap, shampoo, spoon and fork, supplements, vitamins, toothbrush,
toothpaste, wash/kidney basin, medicine cup.

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** FOR
DOCTOR'S PF COVERED VIA MAXICARE RATE
SUPPLIES COVERED EXCEPT OUTPATIENT MEDICATIONS
PLEASE ATTACH BREAKDOWN OF ITEMS USED AND COSTS UPON SUBMISSION OF THE LOA
CLINIC SETTING ONLY

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---

** FOR 1 PT SESSION **
DATE OF AVAILMENT:
**ANY LASER/ SHOCKWAVE PROCEDURES NOT COVERED**

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** FOR GASTROSCOPY/ COLONOSCOPY **

DOCTOR'S PF COVERED VIA MAXICARE RATE
ANESTHESIOLOGIST (IF ANY) SHOULD BE MAXICARE ACCREDITED
REQUIRED TO FILE PHILHEALTH ON THE DAY OF THE PROCEDURE OTHERWISE TO PAY ITS COST
EQUIVALENT
OR TECH SHOULD BE SUBMITTED TOGETHER WITH THE HOSPITAL BILL
DATE OF AVAILMENT:

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----

** FOR 1 SESSION OF DIALYSIS **

DOCTOR'S PF COVERED VIA MAXICARE RATE
REQUIRED TO FILE PHILHEALTH ON THE DAY OF THE PROCEDURE OTHERWISE TO PAY ITS COST
EQUIVALENT
OR TECH SHOULD BE SUBMITTED TOGETHER WITH THE HOSPITAL BILL
DATE OF AVAILMENT:

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----

** FOR PHACOEMULSIFICATION WITH PCIOL **

DOCTOR'S PF COVERED VIA MAXICARE RATE
ANESTHESIOLOGIST (IF ANY) SHOULD BE MAXICARE ACCREDITED
LENS NOT COVERED- C/O PATIENT
REQUIRED TO FILE PHILHEALTH ON THE DAY OF THE PROCEDURE OTHERWISE TO PAY ITS COST
EQUIVALENT
OR TECH SHOULD BE SUBMITTED TOGETHER WITH THE HOSPITAL BILL
DATE OF AVAILMENT:

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** FOR CORONARY ANGIOGRAPHY AS OUTPATIENT **

MAXICARE TO COVER UP TO (RMBL) TO INCLUDE DOCTOR'S PF VIA MAXICARE RATE, MEDICINES
USED FOR THE PROCEDURE, SUPPLIES AND HB
REQUIRED TO FILE PHILHEALTH ON THE DAY OF THE PROCEEDURE OTHERWISE TO PAY ITS COST
EQUIVALENT
OR TECH SHOULD BE SUBMITTED TOGETHER WITH THE HOSPITAL BILL
DATE OF AVAILMENT:

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** WITH APPROVAL OF MBAS CCR MS (APPROVAL CODE: ) **