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Veterans Hospitalization Program (Hospital Reimbursement Form)
PVAO request form for hospitalization reimbursement
Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: Claim No. ______________
_____________________________________________________
(Name of Hospital)
VETERANS HOSPITALIZATION PROGRAM
REQUEST FOR REIMBURSEMENT FORM
Date:
________________
THE DIRECTOR
Veterans Memorial Medical Center
North Ave., Diliman, Quezon City
Madam:
Request reimbursement of expenses incurred during the confinement of the following veterans/dependents in this hospital
in the amount of:________________________________________________________________________ (________________).
(Amount in Words)
(Amount in Figures)
SUMMARY OF PATIENTS’ BILL
PATIENT/S
VETERAN STATUS
RPV-WW II-(WW II Veteran)
RPVD-WWII -(WWII Dependent )
RPV-AFP-(AFP Veteran);
RPVD-AFP-(AFP Dependent)
PERIOD OF
CONFINEMENT
NO. OF
DAYS
AMOUNT
(Date of Admission & Discharge)
Attached are the original copies of the documentary requirements.
Statement of Account/s (with date of Admission & Discharge) signed by the Billing Clerk and the Chief Accountant of the
Hospital
Medical Certificate/s/Discharge Summary (indicating period of confinement)
-
Proof of Veteran Status (photocopy of PVAO ID or VMMC ID; PVAO Certificate)
Thank you.
Very truly yours,
________________________________
Chief of Hospital
