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Veterans Hospitalization Program (Personal Reimbursement Form)

PVAO request form for personal reimbursemet

Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: Claim No. ______________
DEPARTMENT OF NATIONAL DEFENSE
PHILIPPINE VETERANS AFFAIRS OFFICE

VETERANS MEMORIAL MEDICAL CENTER
VETERANS HOSPITALIZATION PROGRAM

REQUEST FOR REIMBURSEMENT FORM
Date:

________________

THE DIRECTOR
Veterans Memorial Medical Center
North Ave., Diliman, Quezon City
Madam:
Request reimbursement of my expenses incurred during my hospitalization/treatment in PVAO-VMMC accredited hospital
and other benefits under the Veterans Hospitalization Program in the amount of:
______________________________________________________________________________________ (P_______________)
(Amount in Words)

(Amount in Figures)

Attached are the documentary requirements for my reimbursement. I understand and will abide by the rules and regulations
set forth in the prioritization and budget scheme of the program.
Thank you.
Respectfully yours,

________________________________
Signature of Patient
Name of Patient:

Veteran Status:
____ RPV-WW II (WW II Veteran)
____ RPV-AFP (AFP Veteran)
____ RPVD-WWII (WWII Dependent) ____ RPVD-AFP (AFP Dependent)

Mailing Address/Telephone No.:

DOCUMENTARY REQUIREMENTS
__ Official Receipt/s
__ Certificate of Confinement/Treatment
__ Proof of Veteran Status (e.g. PVAO ID;VMMC ID; PVAO Certificate)
__ Statement of Account issued by the Hospital (for Hospital Subsidy)
__ Certificate of Waiting List from RDU-VMMC (for Hemodialysis)
__ Audiometry Result (for Hearing Aid)
__ Medical Abstract (for Chemotherapeutic Agent; Orthopedic Implant)
__ Result (for Coronary Angiogram; Angioplasty; Pacemaker Placement)
Additional Requirements (if the patient is deceased):
__ Photocopy of Death Certificate
__ Photocopy of Marriage Contract (claimant shall be the spouse)
__ Identification of the Claimant
(Claimant shall be the son/daughter if both patient & spouse are deceased)
__Photocopy of Death Certificate of the patient and the spouse
__ Birth Certificate
__ Notarized Waiver of Siblings/Deed of Assignment
__ Identification of the Claimant

Evaluated as to Completeness of Documentary Requirements:

FELIZA P. BLANDO
Asst. Chief, Medical Administrative Section

NATURE OF REIMBURSEMENT
___ Angioplasty
___ Cataract Surgery :___(L) ___(R) ___(Both)
___ Chemotherapeutic Agent
___ Coronary Angiogram
___ Dentures : ___ Upper ___ Lower ___(Both)
___ Endoaneurysmectomy for Thoracic/Abdominal Aortic Aneurysm
___ Hearing Aid: ___(L) ___(R) ___(Both)
___ Hemodialysis Dialysis
___ Hernia Mesh
___ Hospital Subsidy
___ Orthopedic Braces
___ Orthopedic Implant
___ Pacemaker Placement ____(Temp) ____(Permanent)

Recommend Approval:

HELEN G. COCSON
Chief, Medical Administrative Section
Approved By:

DOMINADOR M. CHIONG, JR., M.D.
Chairman, VHP Committee

Revised July 2015
 
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