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Republic of he
st ‘SECURITY SYSTEM
Y% SICKNESS NOTIFICATION
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D REPRESENTATIVE
‘PART il- MEDICAL CERTIFICATE (TO BE FLED OUT BY THE ATTENOWG PHYSICAN)
“ATTENDING PHYSICIAN'S
ee ee oa) eee
tat Republic of the Philippines
%y SOCIAL SECURITY SYSTEM
—— ie MEDICAL CERTIFICATE
“THis FORM WAY BE REPRODUCED AND IS NOT FOR SALE THE ESE SORRLETED TERT TE TSE FTE RT wwe
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PARTT-TO BE FLED OUT BY WENGER
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PARTI TO BE FILLED OUT BY ATTENDING PHYSICIAN,
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PERTINENT PHYSICAL EXAMINATION FINDINGS
|DIAGNOSTICIIAR ETS DONE, F ANY (dicate Gate T2aVe waewere Gone)
TE ANY (indicate Galan oT operator)
CONFINEMENT DETAILS
PLACE OF CONFINEWENT
Come \Z/Hospira.
i stitcontnes “Aready discharges BR Bi DATE DISCHARGED muon
TCERTIFICATION
| cert to the folowing
+ That | have seen and examined the above-named patient
+ That the information inthis form are true and correct
+ That the ilnessinjury
(Fox Disability) is permanent in nature. D
(ror Sines) contnerent cluding recuperation prod may at_ “LA _ days,
This certificate is issued for wnateyef qurbete it may serve with regards to the SSS medical claim by the patient
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SIGNATURE OF ATTENDING PHYSICIAN DATE ACCOMPLISHED
[PRO NDIBER gs aerscacn NAN OF PHYSICIAN ST mE
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[CPINIGHOSPITAL ADDRESS:
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INSTRUCTIONS
1. The member's attending physician shall accomplish this form in one (1) copy.
2. Fillout and check all applicable items.
3. PRC number is not require for physician practicing abroad.
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