Scribd
Upload
30 views1 page

Philippines Social Security Medical Certificate

The document is a medical certificate from the Social Security System of the Philippines, intended for use in medical claims. It includes sections for patient history, physical examination, confinement details, and certification by the attending physician. The form must be filled out completely by the physician and is required to support the patient's medical claim.

Uploaded by

Jana Obligado
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
30 views1 page

Philippines Social Security Medical Certificate

The document is a medical certificate from the Social Security System of the Philippines, intended for use in medical claims. It includes sections for patient history, physical examination, confinement details, and certification by the attending physician. The form must be filled out completely by the physician and is required to support the patient's medical claim.

Uploaded by

Jana Obligado
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

_l

Republic of the philippines


SOCIAL SECURITY SYSTEM
MEDICAL CERTIFICATE
PIease read the instructions below before oui this torfi. black inh

[Link] E
.^ L L ,61-tk,

tllAG
k,* fiIVlU,W&r/
[di\qill
$t+ri,l LT ILil
Jn il V
0 fr(},lo',' v, t1 L L4 tUu?ru'fufl fi t1

HISTORY ES U

I hultu ft N LLtttp,u) @ fttr ,JI,r,.


P[RTINEhIT PHYS iCAL EXA{\,,1iNA'rCI.: F Irur,
-1
W',tqLnrhl vtl{,h- on tfi\ Vr w
Jh 641
G U tl

tfuttt a (' C0ttItfU/ U C


I\,UtLfi/ 1
op
w f//.,d

tL/r
PIACE QF CONFtNEMEIIT

6o*, {*r,r^ L (ltA tnt,


6rr,U, dl rhv,tt{
ir^'; aine and ./[Link]:ie$s ni Hospital)
E Sil confined 60,""n^,0"0
L

I certify to the following


That I have seen examined the above-named patient
rhat the i ion in this form are true and corect
That rjury
(For Disability) is permanent jn nature ,1}3a't
[ (For Sickness) confinement inniuding recuperaiicn
periocl may iast fl['7
(No. of days)
days,

This certificate whatever it may serve with regards to the SSS medical clairn by the patient.

RE
M.D.
PHYSICIAN
1 { w h
DATE PLISHED
FIUI\IB (lF i",lAtuiE FHY$iClAli , {Lqsr

cLr ADDRESS
t
I,IAIJ E
fr,trA*qfl:.-'.*.
TELIFHCI!.] Irll::ti:r - : l!t_ :.--.,:
ll\
oN)
\t t rfrtvr t w
OCALITY) .,- ..!
FCSI i i::

1
INSTRUCT}ONS
l The member's attending physician shaii accompijsh
this form in one (1) copy
2, Fill-out and check all applicable ltems.
3. PRC number is not required fcrr physician practicing abroad.

f,/lod cal Cerllilcate paqe 1 of 1

You might also like