B-300 EC Claim For Temporary Total Disability or Sickness

SSS form used for employee sickness notification

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SOCIAL SECURITY SYSTEM

EMPLOYEES NOTIFICATION
   Form B‐300 (8/75)
IMPORTANT: PLEASE READ INSTRUCTIONS AT THE BACK BEFORE FILLING UP FORM

PART I CONFINED MEMBER'S NOTIFICATION (To be filled up by confined member)
NAME OF CONFINED MEMBER (Please Print in Full)

SS NUMBER

TAX ACCOUNT NUMBER

ADDRESS OF EMPLOYER

RESIDENCE OF CONFINED MEMBER

EMPLOYER'S REGISTERED NAME

EXACT DATE OF CONFINEMENT: PLACE/ ADDRESS OF CONFINEMENT

This is to notify my employer that I am currently confined. The name of employer, the place/address and the date when such confinement started are indicated above. I
certify that I am hereby waiving in favor of the SSS all information which my physician has acquired while attending to me as a patient in a professional capacity which
information was necessary to enable him to act in that capacity. I hereby consent to the examination of my physician as to all information acquire by him from physical/ mental
examination of any person and all results of X-ray, laboratory and/or special diagnostic examinations. I further waive all information held privilege by law.

NAME AND SIGNATURE OF MEMBER'S AUTHORIZED REPRESENTATIVE
(If sick member cannot write, print right thumbmark)

SIGNATURE OF CONFINED MEMBER

(RIGHT THUMBMARK)

(Please sign over your printed name)
PART II MEDICAL CERTIFICATE (This block to be filled by attending physician)
I CERTIFY THAT I HAVE EXAMINED/ATTENDED the above‐named employee and state the following:
EXACT DATE EXAMINED ATTENDED

AGE

SEX

CIVIL STATUS

OCCUPATION

ADDRESS OF CONFINEMENT

  THIS IS BEING SUBMITTED AS: (Check applicable box and state corresponding report/ findings)
an INITIAL CERTIFICATE

an INTERMEDIATE

a FINAL CERTIFICATE

           CLINICAL SUMMARY (Please read instruction #4 at the back)

    PROLONGED CONFINEMENT DUE TO:

           DIAGNOSIS

     (a) FINAL DIAGNOSIS (Give progress report of patient)

  IN MY MEDICAL OPINION the confinement including the convalescing 

NO. OF DAYS CONFINEMENT EXTENSION EFFECTIVE (Exact Date)

  or recuperation period may last for __________ days.
  FIT TO RESUME WORK ON ____________________ (estimated date)
Confinement VERIFIED by employer/company physician

CONFINED AT
WILL BE FIT TO RESUME WORK ON (Exact Date)

Confinement NOT VERIFIED by employer/company physician

  PRINTED NAME & SIGNATURE OF ATTENDING PHYSICIAN

 PRINTED NAME & SIGNATURE OF EMPLOYER/ ATTENDING PHYSICIAN

  ADDRESS OF PHYSICIAN

 ADDRESS OF PHYSICIAN

  REGISTRATION/ LICENSE NO.

 REGISTRATION/ LICENSE NO.

  PART III EMPLOYER'S REPORT (This block to be filled up by Employer)
  NAME OF CONFINED MEMBER

OCCUPATION (Exact description of work)

  TIME OF WORK (Inclusive hours)

Date of Employment

HOW LONG EMPLOYED?

  CAUSE OF INJURY

   a) Much less or Tool __________________________________________
   b) Kind of Power (hand, foot, electrical steam, etc.)

DESCRIBE FULLY HOW ACCIDENT HAPPENED AND STATE WHAT EMPLOYEE
WAS DOING WHEN INJURED.

    c) Part of Machine on which accident occurred __________________
    d) Was he injured during his regular occupation? ________________

Time, date & place of accident:
Ti
d t
id

 EMPLOYER'S/ COMPANY'S ACKNOWLEDGEMENT RECEIPT
(FROM SSS)

 EMPLOYER'S ACKNOWLEDGEMENT RECEIPT
(FROM COMPANY)

 NAME OF CONFINED MEMBER

 NAME OF CONFINED MEMBER

 EMPLOYER 

 ADDRESS

 ADDRESS

 EMPLOYER

CONFINEMENT PERIOD (Exact Date)

 START OF CONFINEMENT (Exact Date)

 FROM
RECEIVED BY

TO
DATE RECEIVED

NOTIFICATION RECEIVED BY

DATE RECEIVED

CERTIFICATION BY EMPLOYER
SICKNESS NOTIFICATION WAS RECEIVED BY US ON

START OF CONFINEMENT (Exact Date)

SICKNESS OCCURRED WHILE (working, on leave, etc)

 ______________ 19 ______ thru: Mail/ Phone
COMPANY HAS NO WAY OF VERIFYING THE SICKNESS BECAUSE: (Check applicable box)                   

 _______________________________
 NATURE OF BUSINESS

NO. OF EMPLOYEES  
EMPLOYED

The place of confinement was in

Company has no physician

He/she notified us only upon returning to work on

                                                which is ____________ kms away.
COMPANY ID NUMBER

PRINTED NAME OF SIGNATURE OF COMPANY EXECUTIVE

FOR SSS USE ONLY

MEDICAL EVALUATION
FINAL DIAGNOSIS
APPROVED: ____________________ days, from ____________________ to _____________________
REDUCED: ____________________ days, from ____________________ to _____________________
DENIED: ______________________ days, from ____________________ to _____________________
CLAIMANT TO COME FOR PHYSICAL EXAMINATION/CHEST X-ray

          Submit: ____________________________________   Returned: _______________________________________
PREVIOUSLY APPROVED CONFINEMENT PERIOD: From ___________________________ to _____________________________ 

             

(Exact Date)

(No. of Days)

SIGNATURE OF SSS MEDICAL EXAMINER/ RETAINER PHYSICIAN
RECONSIDERATION/ EXTENSION:

No. of Days

DATE EVALUATED
FROM

TO

MEDICAL EXAMINER

DATE

IMPORTANT INSTRUCTIONS
1. The employee shall notify his employer of his sickness or injury within five (5) calendar days after the start of his confinement. Within five (5) days from receipt of
notice or knowledge of the sickness or injury, the employer shall record in his logbook the facts thereof and within five (5) days thereafter the employer shall notify the
Medical Evaluation Section of the nearest SSS branch or Representative Office. However, in cases where the sickness or injury sustained by the employee while working or
within the premises of the employer, the employee shall be deemed to have notified his employer. The foregoing prescription period of NOTIFICATION does not apply to
HOSPITAL confinement.
2. This form, after having been properly accomplished, shall be submitted in two (2) copies to the Employer by the sick employee or his representative. The employer
shall submit the ORIGINAL to the Medical Evaluation Section of the SSS branch or Representative Office within the prescribed period in instruction No. 1.
3. Use this form for the purposes of an INITIAL SICKNESS NOTIFICATION and INTERMEDIATE or FINAL SICKNESS NOTIFICATION, with the Attending Physician
checking the proper box in the PART II, (Medical Certificate Portion) of this form.
4. For the items "CLINICAL SUMMARY" and " PROLONGED CONFINEMENT DUE TO" in PART II of the form, symptoms, physical findings, laboratory examinations
and reports; X-ray plates; special diagnostic procedures. If any, must be submitted with this form. In cases of prolonged confinement, a progress report of the patient, in
addition to those already stated, must be submitted. If spaces provided are not enough, attach an additional sheet herewith.
5. In cases of prolonged confinement or sickness of the employee that will extend beyond the initial estimate, on a previous estimated period, this form will be
accomplished again by the employee and his Attending Physician, and submitted to the SSS within five (5) days requirement, after the previous estimate, and the Attending
Physician will check the applicable boxes in PART II thereof.
6. For further details, refer to EC Circular No. 2-1 re: Sickness Notification requirement and procedures.
7. Physical examination will be held only in the morning from 8:00 to 12:00, Monday thru Friday. Those who cannot come should notify the SSS, Medical Evaluation
Section of the SSS branch or Representative Office immediately.