Mezzanine, Grand Riviera Suites
Roxas Blvd. corner Padre Faura St., Ermita, Manila
Contact Nos.: 8247 1878 / 8521 9927 / 8293 2484 /
8371 4532 / 8365 5233 / 8371 4511 / 8365 8469 /
0977 804 2137 (Globe) / 0925 652 1927 (Sun)
carehealthplus@gmail.com
www.carehealthplus.com
Letter of Authorization (LOA)
DENTAL - PROCEDURE
To
DIVINE GO- DAVID DENTAL CLINIC
Address of Provider
Unit 2-D Pilar Building, Rd. 1 cor Rd. 3, Project 6,
Quezon City
RTA
RTA-2307540240
PAN LBAD2410102-072623
LOA
DP-1456757
Date LOA Issued
July 26, 2023
Valid Until August 04, 2023
Member’s Name
MARIE CRISELLE
CASIM
Date of Birth
October 19, 1997
Age
25
Company Name
VIRTUAL ASSISTANCE SERVICES ACCESSIBLE VA REMOTE IV
Gender
Female
Health Card Number
GVN02-0000166440 P
Effectivity Expiry Date
Plan Status
ACTIVE
August 31, 2022 to August 30, 2023
This is to confirm that the person whose name is indicated hereunder is a bonafide Member of CareHealth Plus Systems International, Inc.
Chief Complaint: (Member‘s report of illness/injury) Cc: DC, OP, TF
History:
APE Tests / Procedures (Diagnostic / Therapeutic)/ Dental
Procedures:
Member’s Signature: (Member to sign opposite each procedure
after it was done)
Dental Consult, Oral Prophylaxis, Temporary Filling
---Nothing Follows--MARIE CRISELLE CASIM
DR. DIVINE GO-DAVID
Member’s Signature over Printed Name
Prepared By:
MARLO DEHINO PAPA
Date and Time Prepared:
July 26, 2023 / 8:29:am - 11:40:am
Checked By:
MOUNIEN M. ODRA
Date and Time Checked:
July 26, 2023 / 11:40:am
Dentist’s Signature over Printed Name
Reviewed By:
MOUNIEN M. ODRA
Date and Time Reviewed:
July 26, 2023 / 11:40:am
REMINDER Please attach this Letter of Authorization (LOA) together with the other supporting documents to the Statement of Account (SOA)
and send to CareHealth Plus, Mezzanine, Grand Riviera Suites, Roxas Blvd. cor. Padre Faura St., Ermita, Manila. Thereafter, kindly advise
CareHealth Plus through call at (02) 8293 25 85 or e-mail at pa.carehealthplus@gmail.com.
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