Date ________________
CHC 5 Mapalacsiao Birthing Home
NO BILLING POLICY INFORMED CONSENT/WAIVER FORM
I____________________________________________________________, ______Y/O (age)
(Printed name of patient/guardian)
Residing at_________________________________________________________
(Address)
fully RECOGNIZED and ACKNOWLEDGED that following were strictly complied and observed
during our stay and confinement here at CHC 5 Mapalacsiao Birthing Home as enumerated.
1.
2.
3.
4.
5.
NO professional fees were collected upon discharged
NO fees were collected on laboratory work ups upon discharged
NO charges were collected on medicines or drugs upon discharged
NO miscellaneous fees were charged upon discharged
NO other fees or expenses were charged above and beyond the Philhealth packaged
rate
6. NO payment for prescription fee, S2 form, processing for PhilHealth claim forms
or the like were charged.
7. The facility did not require us to sign any document that waives our NBB benefit or
privileges.
Acknowledged and Conforme:________________________________________________
(signature over printed name of patient/guardian)/ date__________________
Attested By: _______________________________________________________________
(signature over printed name / Doctor,nurse ,midwife)/ date________________