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Cooperative Health Management Federation: Letter of Authorization (Loa)

This document is a Letter of Authorization from the Cooperative Health Management Federation to a hospital or clinic. It authorizes medical treatment for a named member and specifies coverage limits for emergency care, outpatient consultations, confinement, and other services. It instructs the hospital to apply the member's PhilHealth/ECC benefits to covered expenses and bill any uncovered charges to the member before discharge. It provides contact information for the Federation and requires itemized bills to be submitted within 30 days.

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Lucy Marie Ramirez
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395 views1 page

Cooperative Health Management Federation: Letter of Authorization (Loa)

This document is a Letter of Authorization from the Cooperative Health Management Federation to a hospital or clinic. It authorizes medical treatment for a named member and specifies coverage limits for emergency care, outpatient consultations, confinement, and other services. It instructs the hospital to apply the member's PhilHealth/ECC benefits to covered expenses and bill any uncovered charges to the member before discharge. It provides contact information for the Federation and requires itemized bills to be submitted within 30 days.

Uploaded by

Lucy Marie Ramirez
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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COOPERATIVE HEALTH MANAGEMENT FEDERATION

Rm.208-209 Malakas Suites, No. 88 Malakas St., Brgy. Pinyahan, Central District, Diliman, Quezon City, Philippines
Tel. Nos.: (02) 283-2321 * (02) 931-0387 Email Add: onecoophealth@gmail.com

LETTER OF AUTHORIZATION (LOA)


LOA Number: ____________

IMPORTANT : Please apply Philhealth / ECC benefits to all applicable expenses.


For any inquiry, please call Cooperative Health Management Federation.
Membership Assistance Department at Tel. # 283-2321 /931-0387

TO : ____________________________________________________ ADDRESS: __________________________________________


(HOSPITAL / CLINIC)

NAME : ____________________________________________________DATE : __________________________________________

COMPANY : __________________________________________________ MEMB. CARD #:_ ____________________________________

 EMERGENCY CARE TREATMENT Maximum Hospitalization Limit ______________


 OUT PATIENT / CONSULTATION A. Room Accommodation ______________
 CONFINEMENT B. Hospital Bill ______________
 OTHERS C. Professional Fee ______________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

* If patient is accommodated in a higher room category, member will shoulder all resulting incremental expenses in room and
board, in ancillary services and professional fees. Likewise, all miscellaneous, personal charges and take home medications and
other services not included in the Service Agreement must be charged accordingly before discharge.

___________________________________
COOP HEALTH AUTHORIZED SIGNATURE

Forward Hospital Bills within 30 days from discharge to Cooperative Health Management Federation at the above address.

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