‘Repubile of he Philippines 4 OFFICE OF THE PRESIDENT ) PHILIPPINE CHARITY SWEEPSTAKES OFFICE, (uezon Cay INDIVIDUAL MEDICAL ASSISTANCE PROGRAM (IMAP) APPLICATION FORM REFERENCE NO.: PETSA (Date): Sagutan ang lahat ng patlang at lagyan ng tsek “W" ang angkop nasagot. (il ue oll the book spacer and check the answer thot opps) 1. DIBAGONG APLIKANTE DATING APLIKANTE (New Applicant) (0¥¢Aowicant)| 2. BUONG PANGALAN NG PASYENTE: (Fat Nome of Paver) ‘APELNIOO Sumame) PANGALAN Given name} BLTIRAHAN (Adttess) PermanenteyPermanent No. Street. Bray. ‘Manicpalty/Gity Province TRegion ‘Gransamantalarrempora No Street. Bray. ‘Moniepaliey/city Province Reson 4.KATAYUANG SIBIL: — DWalangAsawa (singe) Cikasalyvorres) (Grtstaws) DBalo(widowier) Ditiwalayrsenortea) iMay Kinakasama (wih common tw Parner) Gothers roku 5, PETSA NG KAPANGANAKAN, 6. EDAD 7.KASARIAN: — Dilalake Dsabae (Girth date) cola ‘aed (sen 8, NATIONALITY 9. RELIGION (einen). 10.NATAPOS NA ANTAS NG PAG-AARAL: (ighes eoucaiontatoinment/EWPost-graduate (Bligh Sehaot vocational Detementary Dcoliege walang atapes one) 111, HANAPBUHAY. 12, BUWANANG KITA. {ecupation} [Month income) 113. MIYEMBRO NG PAMIILYA NA KASAMA SA BAHAY (HOUSEHOLD FAMILY COMPOSITION) i [ PANGALAN EDAD | KATAYUANG) | RELASYONSA | NATAPOSNA | HANAPBUHAY | BUWANANG (tome) ae) sit PASYENTE | PAGAARAL (Occupation) KITA Gisious) | Yreiotonte Potent) | (caveotonol (Monthy income) | atin) i / {14 TBA PANG PINAGKAKAKITAAN (oTeR SOURCES OF WOME) Sources within the household Sources outside the household Total Monthiy income Total Monthly Income 15. IBA PANG GASTUSIN (orien exenorrunes) Pagkain (Food) P Bahay (Housing) Edukasyon Education) “Transportasyon (Transportation) tba pang gastusin (Miscellaneous) “otal Monthly Expencitures (TM) P “otal Gross Monthy income (TGA) P (Sources within + ouside Househol Net Monthly income (roMerae) 116. MIYEMBRO NG PHILHEALTH? CMember ‘ependent Non-Member17, DIAGNOSIS 18, HINIHINGING TULONG: in-patient Clout-Patient (ieture of Requested Assistance) COPAGPAPA-OSPITAL/confinement) CODIALYSIs:__HemooMauysis, CILABORATORY/DIAGNOSTIC PROCEDURE PERITONEAL TURUYIN Ps sec). CO CHEMOTHERAPY CAMEDICAL DEVICE (Pacemaker, stent ete.) [RADIATION THERAPY CAGAMOT ertecicines) CIASSISTIVE DEVICE (tearing Aid, Wheeichar, Prosthesis etc) CIUNON. & MINIMALLY-OOINVASIVE PROCEDURES (DAnti-Rabies () Psychiatrie (ESM, Endescopy,taparscopic Procedure, et) (Post-op (Post-Transplant {)Factor8,9 —() Antibiotics COTRANSPLANT ai. speci, (DOR Medicines ()1vig () Others (Ps. speci) COREHABILITATIVE THERAPY (@hysicat/Occupetona/SpeechTheropy) COKAGAMITAN SA OPERASYON surgica/supptes) IMPLANT (Bone, cocheor ete) 19, KUNG DATING APLIKANTE GlorieRs joi specs) URI, HALAGA NG TULONG AT KAILAN NATANGGAP ITO MULA SA PCSO (rype ond Amount of révousAssdtonce and Date Received) Using Tulong (notre of Request) Halaga (Amount) Petsa (OoteReceved) 20, Lagyan ng tsek ““” ang pinaka-angkop na sagot ayon sa iyong nalalaman at tunay nakalagayan sa buhay, {check he best answer the applies based on mhat you know and your oct suion ) MGA KATANUNGAN(Quetins/Quaifiers) = MGA KASAGUTAN (ance) Y] POINT SCORE 1UWAG MAGSULAT DITO) 41. Paslidad na Pangkalusugen at ‘URING OSPITAL (r¥PE OF HosPrraL) Pampubiko/Gobyerno (Government) Krag ot itokaajon gravee asacyn ng Poses TUASPIASYON No PATENT ane oF aloes ee Private/Pay_ Tepe RApglTo (cmergency admission) 2. Bakit napasok sa pribadong ospltal? (What isthe reason for amision ot 2 rivoteoy hospital) "Walang bakante/kakayanan sa pampublikong ospltal (No vaconees/needed facies in Goverment hase) Pinakamalapit na ospital sa tntirhan (Neorest Rosia (ron pst Kagustuhan dahil Private hospital preferred de to} May kakilala (Acquaintance i hospital) # Payong doctor (Ooeter'sacice} + _sarling desisyon (Own decision) Dahil sa sakit (Ove tonature of ess) 3, Bakit napasok sa pribadong kwarto? (that isthe reason fr odmision at a prvate Walang bakante/pune ang mas murang kwarto io walle cheaper roms/ charity beds) foot Kagustuhan dahil (Room of choice due to (ron m-paners © May kakilala Acquaintance in haspital) 2 Saritng desisyon (own decision) cy Po -P 800 4. Haloga ng Kuwarto P_ao1_-Pi, 200 mtied [PL201_-P 1,600 (ronmennenr) LAA PaO P2,001 -P 2,400 2,403 pataas(P240i ond above) PO - P10,000 10,001 — 20,000 20,001 — 30,000 5, Magkano ang naliwang buwanang kita ig parilya? (Umar isthefomiy’s total net menthy Income?) 30,001 = P 40,000 40,001 pataas (P 40.001 and above)8. Ano ang tungluling inagampanan ng pasyente sa parliya? {Wiha ste oe of he parent in the fama) Pangurahing sumasagot sa pangangallangang ppinansyal ng pamilya (woin provier/oreodwiner} "Nakakaambag sa pangangallangang pinansyal ng pamilyatconuibstor) Walang kita nguni't may ginagampanang ibang ‘ungkulin sa tahanan(Perorms other complementary roles, such es housshold upkeep) Ganap na umaasa sa ibang kasapi ng pamilya para Sa mga pangangailangan(rutyaepensent on ater fry members) 7. Anwano ang mga panseriling suliraninang kinakaharap ng pamilya sa ngayon? (Wht are the personal creumstonces being {foced bythe foray?) “Magkakaibang suliraninang Kinakaharapiutinte rableme) Mga sitwasyong naglalagay sa pamilya sa Kriss, tulad 1g pagkakasakit ng ibang miyembrang pamilya, Pagiging biktima, atbp. (Cisisstumions suchatsictnessof | | ‘other famiy members, itmize, ete) ‘Mga natatanging sitwasyon, tulad ng mga may kapansanan, naulila/pinabayaan, nabalo, senior, atbp. (speci stuations such os alferenty abled, owphor/abardoned, wicew senior ctzen, et, Mga aksidente na walang mananagot sa pinsalang, natamoyAccidents without 3 party hail ‘May problema sa relasyon sa pagitan ng mga rmiyembrong patilyatramiy reltional robles) 8. Ano ang stwasyon a trahan ng ppamilya? (Wht ste for’ housing ‘stution?) ‘Nawalan ng tirahan dahil sa kalamidad\oiplaced Sue to calority) Pansamantalang nakikitra/Tronsient/emoorl 1 Nakatira sa lupain ng iba/iskwater inform setuer) Nangungupahan/tenter) Nakikitira sa kamag-anakpovse Sharer) May-arl ng bahayiHemeowne) 2 High-ne communsty = Middle Cass + tow cost houng TOTAL SCORE CLASSIFICATION. I Pinatutunayan ko na ang lahat ngiinilahad ko dito ay pawing totoo at tama ayon sa aking kaalaman at ‘Aakayahan. Nababatid at naiintindihan ko na anumang maling impormasyon na aking sadvang ibinigay ay maaaring ‘maging dahilan na hindi mapagbigyan ang aktag kahilingan at maging dakilan sa paghabla ng kasong tigal laban sa akin hereby cerfy that al he iforiiion ws stated above are tas and corect based on my knowledge and eapociy. J understand that cay also stated here may result n the resection of my request and ie ling of egal charges agains! me) VALIDATED BY: Medical Social Worker Lagda o Thumbmark ng Aplikante sa Itaas ng Pangalan ‘Signature or TumbmarkAbove Apolicant's Piste Name ID na Ipinakita/vais 0 presented) Kung walang ID, Sertipikasyon/Pruweba ng Pagkakakilanlan Inilevof i, Ceniation/Prof of entity, Kung kinatawan, RelasyonsaPasyente(acation to Patient). NumerongTelepono(contact No)