Consultation Outpatient Procedure: Outpatient Letter of Authority Outpatient Letter of Authority

4F Civic Prime Building Unit 405-410, Civic Drive 4F Civic Prime Building Unit 405-410, Civic Drive
Filinvest, Alabang, Muntinlupa City 1781 Filinvest, Alabang, Muntinlupa City 1781
0917-8055424 & 0917-8855424 (calls only) 0917-8055424 & 0917-8855424 (calls only)
0917-8255424 & 0917-8955424 (call and text) 0917-8255424 & 0917-8955424 (call and text)
Tel. No.: (632) 8844-5773 / Fax No.: (02) 8886-4478 Tel. No.: (632) 8844-5773 / Fax No.: (02) 8886-4478
OUTPATIENT LETTER OF AUTHORITY OUTPATIENT LETTER OF AUTHORITY

CONSULTATION OUTPATIENT PROCEDURE
1. Copy of this LOA should be faxed by the doctor to (02) 8886-4478 or sent to CREDIT & 1. Patient should present this copy to Credit and Collection for validation.
COLLECTION of the hospital to be submitted within 30 days to Lacson & Lacson Insurance Brokers, 2. Patient must present validated laboratory form to the laboratory section of the accredited hospital
Inc. for payment of consultation fee. for prescribed procedures to be done.
2. If laboratory / diagnostic tests are required, doctor should return a copy to patient. 3. Credit and Collection should forward all billings with copy of this laboratory form within 30 days to
Lacson & Lacson for collection of payment.
Date/Time : December 10, 2023 / 06:40:18 am (valid for 30 days from date of issuance)
Doc No. : PAGS-2023-x-02747 Date/Time : December 10, 2023 / 06:40:18 am (valid for 30 days from date of issuance)
Consultation Date : Doc No. : PAGS-2023-x-02747

Consultation Date :
To : Dr.
Medical Center Taguig To : Dr.
Medical Center Taguig
Re : MERCADO, JASON PAUL S
PHILIPPINE AIRPORT GROUND SUPPORT SOLUTIONS INC. Re : MERCADO, JASON PAUL S
(PATIENT) MERCADO, GAVIN G PHILIPPINE AIRPORT GROUND SUPPORT SOLUTIONS INC.
--------------------------------------------------------------------------- (PATIENT) MERCADO, GAVIN G
Complaint : ---------------------------------------------------------------------------
Diagnosis : Complaint :
Diagnosis :
Prescribed laboratory & Diagnostics test(s)

Prescribed laboratory & Diagnostics test(s)
Please honor this electronically generated LOA.

Please honor this electronically generated LOA.
Professional Fee : Professional Fee :

Print Doctor's Name/Signature Print Doctor's Name/Signature
Lilibeth Y. Lacson, EVP Tin : Lilibeth Y. Lacson, EVP Tin :

This Letter of Authority (LOA) provides you access to Lacson & Lacson's network of accredited health care providers This Letter of Authority (LOA) provides you access to Lacson & Lacson's network of accredited health care providers
included in your insurance benefit with your employer. To serve you better, the information you will provide us such included in your insurance benefit with your employer. To serve you better, the information you will provide us such
as your name, employment, age, medical results and documents will be used by our representatives/employees to as your name, employment, age, medical results and documents will be used by our representatives/employees to
process your insurance claim. In the process of helping you out with your claim, we will receive your statement of process your insurance claim. In the process of helping you out with your claim, we will receive your statement of
accounts, medical records, and other documents related to your use of our LOA. This information may be accessed accounts, medical records, and other documents related to your use of our LOA. This information may be accessed
by your employer for the purpose of reviewing your benefits or in conducting survey studies. by your employer for the purpose of reviewing your benefits or in conducting survey studies.
Should you have any concerns about the privacy of your information, please contact us at [email protected] or Should you have any concerns about the privacy of your information, please contact us at [email protected] or
communicate it immediately with any of our client care representatives. communicate it immediately with any of our client care representatives.

Consultation Outpatient Procedure: Outpatient Letter of Authority Outpatient Letter of Authority

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Consultation Outpatient Procedure: Outpatient Letter of Authority Outpatient Letter of Authority

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4F Civic Prime Building Unit 405-410, Civic Drive 4F Civic Prime Building Unit 405-410, Civic Drive

OUTPATIENT LETTER OF AUTHORITY OUTPATIENT LETTER OF AUTHORITY

Consultation Date : Doc No. : PAGS-2023-x-02747

(PATIENT) MERCADO, GAVIN G PHILIPPINE AIRPORT GROUND SUPPORT SOLUTIONS INC.

--------------------------------------------------------------------------- (PATIENT) MERCADO, GAVIN G

Prescribed laboratory & Diagnostics test(s)

Please honor this electronically generated LOA.

Professional Fee : Professional Fee :

Lilibeth Y. Lacson, EVP Tin : Lilibeth Y. Lacson, EVP Tin :

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