1/20/25, 8:35 AM E-Referral Control Sheet

Referral Control Sheet for

*46125701251*
Loa No.: 46125701251
Out-Patient Diagnostic Evaluation (RCS 2) VALID UNTIL:
01/23/2025

RCS Date:
Name of Patient : NOROUZI, HOMEIRA ApCode : GRA-012568-99
01/20/2025 8:35:53 AM
Card Number: 1195020000287664
Hospital/Clinic: THE MEDICAL CITY
Account Number: 80-00-04152-40957-02/18
Birth Date: 03/21/1967 12:00:00 AM
Company: JPMORGAN CHASE BANK N.A. - PGSC
Sex: FEMALE
Validity: 06/30/2025 11:59:59 PM
PEC Limit: 250,000.00
Inclusion:
Max Limit: 250,000.00
Exclusion: SLMC-GC
Room and Board: REGULAR PRIVATE
Remarks: Hospital Bill: 0.00
Ph Required: NO Professional Fee: 0.00

DEPARTMENT
Diagnosis Diagnostic Procedures Done Special Instructions:
__Laboratory __X-Ray
DDD,L4-L5 PT SESSION Covered up to 0.00 excess c/o
__Nuclear patient.
__Ultrasound RCS Remarks
__MRI/CTScan __Heart
St
__Rehabilation __Others

Procedure Done By: Anesthesia Done By: Coordinator:

________________________________ ________________________________ ________________________________

NOROUZI, HOMEIRA TANCHULING, EMILIA HALILI

Parent/Member Printed Name and Signature Requesting Physician/Coordinator's Name and Signature

MEMBER UNDERTAKING AND CONSENT FORM

This Form allows you to provide your explicit and written authorization, consent, and grant of access to and/or collection, processing, and disclosure of your personal and sensitive
personal information, such as your medical records including, but not limited to, your age, residence, past medical history, results of medical examinations, diagnosis, abstracts,
treatments, utilization (collectively referred to as "Information") and to be furnished copies thereof for the specific purpose of evaluating your medical claim under your applicable
Health Plan and to provide health managed care for your employer pursuant to the Health Service /Group Corporate Agreement (Purposes). Should you have questions or
concerns about this form or should you wish to lodge a complaint or correct any information, please email us at [email protected] . For more information on how Intellicare
protects its data and your information, you may visit our website at www.intellicare.net.ph.

By signing this Form, you agree to:

1. Allow the company, through its agents, representatives, personnel, subcontractors, and/or medical facilities connected with the Company including, but not limited to,
physicians, nurses, and consultants, to collect, use and process your personal and sensitive personal information specific only for the purposes mentioned above.
2. Authorize the Company to disclose such Information to its agents and affiliates, including your registered employer, your employer's registered broker if any, and/or the
principal member to which you are a dependent, if applicable.
3. Permit the Company to generate reports from the Information collected and share the same to the entities mentioned under item no. 2 above. For this purpose, your
Information will be stored by the Company for a period of five (5) years, without prejudice to your rights as a data subject.
4. Give consent to the identified hospital or physician to release your Information and related documents, including a summary thereof derived from laboratory services and
medical consultations, to the Company or its authorized representatives for the evaluation of your medical claim and for the Company to disclose such information to entities
mentioned under item no. 2 above..
Kindly note that if you decide not to sign this document,INTELLICAREwill not be able to process your requested transaction.
DATA PRIVACY CONSENT & WAIVER
I, the undersigned, have read the foregoing statement and hereby express my consent to the above. I further understand (a) the reasons for the collection, processing, and
disclosure of my Information and the ways in which said Information may be used, and I agree to said usage and disclosure; and that (b) it is my choice as to what information I
provide and that withholding or falsifying information might act against the best interests of my assessment. I also acknowledge that the Company has and will always take
commercially reasonable steps to protect and maintain the confidential nature of my personal information in accordance with its applicable privacy policies. I hereby affirm my right
to be informed, object to processing, access and rectify, suspend or withdraw my information, and be indemnified in case of damages pursuant to the provisions of Philippine Data
Privacy Law, other applicable laws, rules and regulations.

OTHER UNDERTAKINGS
I, likewise, acknowledge that all of the procedures indicated in this document had been done. I promise to pay for any procedure and professional fees not explicitly covered by the
provisions of the Health Service /Group Corporate Agreement. Furthermore, by virtue of this undertaking, I hereby render the Company free from any liability on the collection of the
acquired non-coverable charges (i.e. excess in limits, exclusions, etc.). I fully understand that in instances wherein payables were not settled upon availment, I will be subjected to
credit documentation and will be charged of administrative fees as applicable.
NOTE: If this RCS has been signed with an electronic signature the signatories hereto consent and agree to the use of such electronic signature with respect to this RCS pursuant
to the Philippine Electronic Commerce Act or as amended from time to time and the signatories, hereby waive any objection to the contrary.

________________________________________ ______________________
Signature over Printed Name Date
------------------------------------------------------------------------------------------------------------------------
Intellicare 7th Floor Feliza Bldg., V.A. Rufino Street, Legazpi Village Makati City.
#Tel. 789-4000 For TEXT ONLY(smart-0920-951-8452) (sun-0922-891-3925)(globe-0917-805-2502) CALL ONLY(smart-0920-970-4724)(sun-0922-891-3957) (globe-0917-840-
4894)

https://calamba.intellicare.ph/webcallcenter/RCS2-Print.aspx 1/2
1/20/25, 8:35 AM E-Referral Control Sheet

Referral Control Sheet for *46125701251*

Out-Patient Diagnostic Loa No.: 46125701251

Evaluation (RCS 2) VALID UNTIL: 01/23/2025

RCS Date:
Name of Patient : NOROUZI, HOMEIRA ApCode : GRA-012568-99
01/20/2025 8:35:53 AM
Card Number: 1195020000287664 Hospital/Clinic:
Account Number: 80-00-04152-40957-02/18 THE MEDICAL CITY Birth Date:
Company: JPMORGAN CHASE BANK N.A. - PGSC 03/21/1967 12:00:00 AM Sex:
Validity: 06/30/2025 11:59:59 PM FEMALE
PEC Limit: 250,000.00
Inclusion:
Max Limit: 250,000.00
Exclusion: SLMC-GC
Room and Board: REGULAR PRIVATE
Remarks: Hospital Bill: 0.00
Ph Required: NO Professional Fee: 0.00

DEPARTMENT
Diagnosis Diagnostic Procedures Done Special Instructions:
__Laboratory __X-Ray
DDD,L4-L5 PT SESSION Covered up to 0.00 excess
__Nuclear c/o patient.
__Ultrasound RCS Remarks
__MRI/CTScan __Heart
St
__Rehabilation __Others

Procedure Done By: Anesthesia Done By: Coordinator:

________________________________ ________________________________ ________________________________

NOROUZI, HOMEIRA TANCHULING, EMILIA HALILI

Parent/Member Printed Name and Signature Requesting Physician/Coordinator's Name and Signature
MEMBER UNDERTAKING AND CONSENT FORM

This Form allows you to provide your explicit and written authorization, consent, and grant of access to and/or collection, processing, and disclosure of your personal and sensitive
personal information, such as your medical records including, but not limited to, your age, residence, past medical history, results of medical examinations, diagnosis, abstracts,
treatments, utilization (collectively referred to as "Information") and to be furnished copies thereof for the specific purpose of evaluating your medical claim under your applicable
Health Plan and to provide health managed care for your employer pursuant to the Health Service /Group Corporate Agreement (Purposes).
Should you have questions or concerns about this form or should you wish to lodge a complaint or correct any information, please email us at [email protected] . For more
information on how Intellicare protects its data and your information, you may visit our website at www.intellicare.net.ph.

By signing this Form, you agree to:

1. Allow the company, through its agents, representatives, personnel, subcontractors, and/or medical facilities connected with the Company including, but not limited to,
physicians, nurses, and consultants, to collect, use and process your personal and sensitive personal information specific only for the purposes mentioned above.
2. Authorize the Company to disclose such Information to its agents and affiliates, including your registered employer, your employer's registered broker if any, and/or the
principal member to which you are a dependent, if applicable.
3. Permit the Company to generate reports from the Information collected and share the same to the entities mentioned under item no. 2 above. For this purpose, your
Information will be stored by the Company for a period of five (5) years, without prejudice to your rights as a data subject.
4. Give consent to the identified hospital or physician to release your Information and related documents, including a summary thereof derived from laboratory services and
medical consultations, to the Company or its authorized representatives for the evaluation of your medical claim and for the Company to disclose such information to entities
mentioned under item no. 2 above.
Kindly note that if you decide not to sign this document,INTELLICAREwill not be able to process your requested transaction.
DATA PRIVACY CONSENT & WAIVER
I, the undersigned, have read the foregoing statement and hereby express my consent to the above. I further understand (a) the reasons for the collection, processing, and
disclosure of my Information and the ways in which said Information may be used, and I agree to said usage and disclosure; and that (b) it is my choice as to what information I
provide and that withholding or falsifying information might act against the best interests of my assessment. I also acknowledge that the Company has and will always take
commercially reasonable steps to protect and maintain the confidential nature of my personal information in accordance with its applicable privacy policies. I hereby affirm my right
to be informed, object to processing, access and rectify, suspend or withdraw my information, and be indemnified in case of damages pursuant to the provisions of Philippine Data
Privacy Law, other applicable laws, rules and regulations.
OTHER UNDERTAKINGS
I, likewise, acknowledge that all of the procedures indicated in this document had been done. I promise to pay for any procedure and professional fees not explicitly covered by the
provisions of the Health Service /Group Corporate Agreement. Furthermore, by virtue of this undertaking, I hereby render the Company free from any liability on the collection of the
acquired non-coverable charges (i.e. excess in limits, exclusions, etc.). I fully understand that in instances wherein payables were not settled upon availment, I will be subjected to
credit documentation and will be charged of administrative fees as applicable.
NOTE: If this RCS has been signed with an electronic signature the signatories hereto consent and agree to the use of such electronic signature with respect to this RCS pursuant
to the Philippine Electronic Commerce Act or as amended from time to time and the signatories, hereby waive any objection to the contrary.

________________________________________ ______________________
Signature over Printed Name Date
------------------------------------------------------------------------------------------------------------------------
Intellicare 7th Floor Feliza Bldg., V.A. Rufino Street, Legazpi Village Makati City.
#Tel. 789-4000 For TEXT ONLY(smart-0920-951-8452) (sun-0922-891-3925)(globe-0917-805-2502) CALL ONLY(smart-0920-970-4724)(sun-0922-891-3957) (globe-0917-840-
4894)

https://calamba.intellicare.ph/webcallcenter/RCS2-Print.aspx 2/2