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B301 EC Medical Reimbursement Benefit Application
SSS form used for EC medical reimbursement
Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: Republic of the Philippines
SOCIAL SECURITY SYSTEM
EC MEDICAL REIMBURSEMENT BENEFIT APPLICATION
FORM B301
(Rev. 02/97)
PLEASE READ INSTRUCTIONS AT THE BACK BEFORE FILLING UP
Page 1
PART I - EMPLOYER TO FILL IN ALL ITEMS
ACCIDENT/SICKNESS REPORT
NAME OF EMPLOYEE
SS NUMBER
HOME ADDRESS
ZIP CODE
AGE
SEX
M
F
OCCUPATION (State brief description of duties/Specify name of chemicals or substances to which the employee is exposed)
NAME OF EMPLOYER AT THE TIME OF ACCIDENT/SICKNESS
ID NUMBER
ADDRESS
ZIP CODE
PERIOD OF EMPLOYMENT
From
REGULAR WORKING HOURS
To
AM
PM To
From
DATE OF ACCIDENT/ONSET OF SICKNESS
OVERTIME SCHEDULE
AM
PM
AM
PM To
From
TIME OF ACCIDENT/SICKNESS
AM
PM
PLACE OF ACCIDENT/SICKNESS
AM
PM
BRIEF DESCRIPTION OF ACCIDENT/SICKNESS (Specify where employee was going at the time of accident or the purpose of the trip and describe
the circumstances of the accident)
PART II - JOINT CERTIFICATION
We hereby certify that all the above information are true and correct.
PRINTED NAME AND SIGNATURE OF
IMMEDIATE SUPERVISOR
PRINTED NAME AND SIGNATURE OF AUTHORIZED
COMPANY REPRESENTATIVE
(If member cannot sign/deceased)
RIGHT THUMBPRINT
(in lieu of signature)
PRINTED NAME AND SIGNATURE OF EMPLOYEE
PRINTED NAME AND SIGNATURE OF WITNESS
NOTE: ANY MISREPRESENTATION OR FALSIFICATION SHALL BE SUBJECT TO FINE AND IMPRISONMENT UNDER THE
LAW (P.D. 626, ARTICLE 207)
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(SURNAME)
Internet Edition (7/2000)
SS NUMBER
(FIRST NAME)
(MIDDLE NAME)
○
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DATE RECEIVED
NAME OF EMPLOYEE
○
PLEASE PRESENT THIS RECEIPT WHEN INQUIRING
ABOUT THE STATUS OF YOUR APPLICATION.
VERIFICATION WILL BE ENTERTAINED AFTER _____
DAYS FROM THE DATE OF RECEIPT.
FOR SSS USE ONLY
NAME OF PAYEE
○
TO BE FILLED UP BY EMPLOYER/EMPLOYEE
FORM B301 (Rev. 02/97)
RECEIVED BY
○
SOCIAL SECURITY SYSTEM
EC MEDICAL REIMBURSEMENT
CUT HERE
ACKNOWLEDGEMENT STUB
INSTRUCTIONS
1. Fill in all items properly. Please type or print legibly.
2. Attach the following in cases of:
a) vehicular accident
• police report
• specify employee’s destination and purpose of the trip
b) medico-legal incident
• police report
• specify motive of the aggressor in inflicting the injuries
c) work-related illness
• pre-employment physical examination report/ chest x-ray/ ECG reports.
• pertinent clinical records/laboratory and other diagnostic procedures.
Note: Employee’s Compensation claims should be filed within 3 years from date of
work-related accident or illness.
Republic of the Philippines
SOCIAL SECURITY SYSTEM
EC MEDICAL REIMBURSEMENT BENEFIT APPLICATION
FORM B301
(Rev. 12/95)
PLEASE READ INSTRUCTIONS AT THE BACK BEFORE FILLING UP
PART I - PAYEE/CLAIMANT TO FILL IN ALL ITEMS
PAYEE/CLAIMANT
Page 2
Initial Claim
ADDRESS OF PAYEE
Related/Subsequent
ECC ID NO.
ZIP CODE
ECC ID NO.
ZIP CODE
ECC ID NO.
ZIP CODE
PAYEE/CLAIMANT
ADDRESS OF PAYEE
PAYEE/CLAIMANT
ADDRESS OF PAYEE
PART II - HOSPITAL TO FILL IN ALL ITEMS
NAME OF HOSPITAL
ECC NUMBER
Out-patient
ADDRESS:
DATE ADMITTED
CHARGES
Confined
DATE DISCHARGED
AMOUNT CLAIMED
AMOUNT ALLOWED
A. MEDICINES
B. LABORATORY
C. X-RAY/ULTRASOUND
D. PHYSICAL THERAPY
E. HOSPITAL ROOM/ER
F. OPERATING ROOM
G. CENTRAL SUPPLIES
H. MISCELLANEOUS/OTHERS
TOTAL
I CERTIFY THAT THE SERVICES CLAIMED ARE DULY RECORDED IN THE PATIENT’S CHART AND THE INFORMATION GIVEN IN THIS FORM,
INCLUDING THE ATTACHED COPY OF THE PATIENT’S STATEMENT OF ACTUAL CHARGES, IS CORRECT.
PRINTED NAME AND SIGNATURE OF AUTHORIZED REPRESENTATIVE
POSITION
PART III - DOCTOR TO FILL IN ALL ITEMS
DIAGNOSIS
PARTS OF THE BODY AFFECTED
PROFESSIONAL FEE
PRINTED NAME AND SIGNATURE OF ATTENDING PHYSICIAN
ECC NUMBER
SERVICES RENDERED
PRINTED NAME AND SIGNATURE OF SURGEON
APPROVED
(For SSS use only)
NUMBER OF VISITS
ECC NUMBER
SERVICES RENDERED
PRINTED NAME AND SIGNATURE OF ANESTHESIOLOGIST
TIN
TIN
NUMBER OF VISITS
ECC NUMBER
SERVICES RENDERED
TIN
NUMBER OF VISITS
PART IV - AUTHORIZATION
I AUTHORIZE THE HEREIN-NAMED HOSPITAL/EMPLOYER/PHYSICIAN/PROVIDER WHO PROVIDED/PAID THE MEDICAL SERVICES,
APPLIANCES AND SUPPLIES TO FILE AN EMPLOYEES’ COMPENSATION MEDICAL EXPENSE CLAIM UNDER P.D. NO. 626 FOR PAYMENT
OF SERVICES RENDERED TO ME DURING MY TREATMENT AND THE RELEASE TO THE SSS/EC OF ANY INFORMATION NEEDED FOR
THIS OR A RELATED EC CLAIM. I AGREE TO PAY REASONABLE EXPENSES INCURRED IN EXCESS OF WHAT ARE REIMBURSABLE
UNDER EC MEDICAL SERVICES AND ANY PORTION OF THE CLAIM SUBSEQUENTLY DISALLOWED BY SSS.
(If member cannot sign/deceased)
PRINTED NAME AND SIGNATURE OF EMPLOYEE
Internet Edition (7/2000)
RIGHT THUMBPRINT
(In lieu of signature)
PRINTED NAME AND SIGNATURE OF WITNESS
INSTRUCTIONS
1. Fill in properly all blank spaces.
2. Indicate complete diagnosis including body parts affected:
- head/neck - upper extremities
- eyes
- arms
- trunk
- head
- spine
- lower extremities
- legs
- foot
- others
3. If claimant is employee or employer, attach the following:
a. original official receipt with BIR permit number
b. charge slips or statement of account with itemized list or breakdown of
expenses
4. If claimant is hospital, attach charge slips or statement of account with
itemized list or breakdown of expenses.
5. If member is unable to sign, affix thumbprint, with printed name and signature
of witness to thumbprint.
6. If member is deceased, indicate the relationship on the employee portion, with
printed name and signature of witness.
7. Use another sheet if there are more than three payees.
