Version 18.

0 – 22 May 2023
Control Number: FT-PAD-02
Republic of the Philippines
Office of the Vice President

MEDICAL ASSISTANCE APPLICATION FORM

(PAALALA: LAHAT PO NG MGA PORMA AT PROGRAMA NG TANGGAPAN NG PANGALAWANG PANGULO AY LIBRE AT WALANG BAYAD)

Date of Interview Record Number

Application - To be filled out by the client:

FIRST NAME MIDDLE NAME LAST NAME

Name of Patient

MONTH, DAY, YEAR Age Sex Person with Disability (PWD)

Date of Birth Male Female Yes No

Current Address

Contact Number
Diagnosis

Dialysis Center/ DOH Signature

Hospital’s Name

Family’s Monthly Occupation

Income

Details of Authorized Representative

FIRST NAME MIDDLE NAME LAST NAME
Name of Authorized
Representative
Age Sex Signature
Relationship to
the Patient Male Female

E-mail Address
Contact Number

Please be informed that sensitive, confidential, and personal data/information, collected by the OVP in relation to your request for medical assistance shall be
used solely for the processing of your request and shall not be forwarded to any external agency or organization without your consent, subject to the provisions
of the Data Privacy Act of 2012.

Furthermore, under our guidelines, OVP clients can only avail of medical assistance after submission of complete documentary requirements and only once in
every six (6) months. For data privacy related concerns, you may contact the OVP Data Privacy Officer at 11/F Cybergate Plaza, EDSA cor. Pioneer Street,
Mandaluyong City through Tel. No.: 83701711 loc. 1130 or email: dpo@ovp.gov.ph.

Evaluation - To be filled out by the OVP Personnel:

RECOMMENDED FOR APPROVAL Recommending Approval:

For issuance of Guarantee Letter Requested Amount: _________________________

For issuance of medicines in kind Recommended Amount: ______________________

FOR COMPLETION OF REQUIRED DOCUMENTS Remarks:

Please return on: Actual Date of Return:

DENIED
Due to availment of the medical assistance within six (6) months from this date of application
DATE OF LAST AVAILMENT: _______________________________
Invalid/Non-compliant Documents
Blacklisted due to fraud
Others: _____________________

Eligible beneficiaries may submit their applications through the OVP Central Office or Satellite Offices (SO) on Mondays to Fridays, 8:00 AM to 5:00 PM. Early
cut-off time may be implemented to ensure that clients will be served within the day.

11F, Robinsons Cybergate Plaza, EDSA cor. Pioneer St., Mandaluyong, 1550, Metro Manila
Tel. No. 8532-5942/ 8370-1719 vp@ovp.gov.ph
Version 18.0 – 22 May 2023
Republic of the Philippines
Office of the Vice President

CLIENT WAIVER & CONSENT FORM

(PAALALA: LAHAT PO NG MGA PORMA AT PROGRAMA NG TANGGAPAN NG PANGALAWANG PANGULO AY LIBRE AT WALANG BAYAD)

Pangalan (Patient/Representative): __________________________________________________________

Contact Number:__________________________________________________ Date:__________________

Ako ay sumasangayon sa mga sumusunod:

1. Lahat ng impormasyon at dokumentong aking isusumite ay tunay at totoo. Naiintindihan ko na ang
aking ipinasang aplikasyon ay dadaan muna sa pagsusuri upang makumpirma ang katunayan ng mga
dokumento.
2. Anumang mapatunayang kasinungalingan o pag gamit ng mga pekeng dokumento ay magdudulot
ng disqualification o pagkansela ng aplikasyon para sa Medical Assistance Program at maaaring
magresulta sa criminal o civil liability gaya ng pagkakulong at multa.
3. Ang Office of the Vice President (“OVP”) ay maaaring kumuha at gumamit ng aking impormasyon
upang: (a) alamin ang mga pangunahing pangangailangan ng aking komunidad o sektor; (b) bumuo
ng mga plano para tugunan ang mga pangangailangan; (c) i-monitor ang pagpapatakbo o resulta ng
mga plano; (d) ilahad sa ibang tao ang aking karanasan kabilang ang pinagdaanang kahirapan at
anumang tagumpay na nakamtan.
4. Pinapahintulutan ko ang OVP sa pangongolekta, paggamit at pagproseso ng aking personal na
impormasyon alinsunod sa mga layunin na nakasaad dito. Pinapahintulutan ko ang OVP na ibahagi
ang mga impormasyon sa ibang mga partido, lokal man o internasyonal, ayon sa pangangailangan
at nararapat para sa katuparan ng mga layunin at ang paggamit at paglalantad ay makatwiran,
kailangan , pinapahintulutan at naayon sa batas, alinsunod sa Data Privacy Act of 2012 at
Implementing Rules nito.
5. Pinahihintulutan ko ang OVP (o ang Partner) na kunin, irekord, at gamitin sa anumang paraan ang
aking panayam, kabilang ang aking personal na impormasyon, imahe, at tinig, sa kabuuan o bahagi
man, sa mga larawan, bidyo, lathala, audio at iba pang media, sa loob o sa labas ng Pilipinas, para
sa mga layuning nakasaad sa itaas at sa iba pang naaayon sa batas.
6. Wala akong copyright sa alinmang materyal na makakalap, at maaari itong gamitin o i-edit batay sa
sariling pagpapasya ng OVP (o ng Partner) nang hindi nangangailangan ng aking pahintulot at walang
anumang kabayaran kapalit nito.
7. Tunay at kumpletong impormasyon lamang ang ibibigay ko sa OVP.
8. Wala akong kahit anumang pananagutang hihingin mula sa OVP (o sa Partner) sa dahilan ng paggamit
ng impormasyong makakalap.
9. May karapatan at kakayahan akong maisagawa ang pagsang-ayong ito. Wala dito ang sumasalungat
o lumalabag sa anumang pag-unawa o kasunduan na mayroon ako sa sinuman, o anumang
karapatang nauukol sa iba.
10. Ang pagsang-ayong ito ay pamamahalaan ng batas ng Republika ng Pilipinas.
11. Nabasa ko ang mga tuntunin ng pagsang-ayong ito at kusang-loob ko itong isinasagawa nang walang
tinatanggap na anumang konsiderasyon.

SIGNATURE OVER PRINTED NAME

11F, Robinsons Cybergate Plaza, EDSA cor. Pioneer St., Mandaluyong, 1550, Metro Manila
Tel. No. 8532-5942/ 8370-1719 vp@ovp.gov.ph
Version 18.0 – 22 May 2023
Republic of the Philippines
Office of the Vice President

DOCUMENTARY REQUIREMENTS
(PAALALA: LAHAT PO NG MGA PORMA AT PROGRAMA NG TANGGAPAN NG PANGALAWANG PANGULO AY LIBRE AT WALANG BAYAD)

General Requirements List of Valid IDs Alternative IDs for Minors

1. Original Copy of the Medical Application Form. • Driver’s License ● Registered Birth Certificate
Dated and signed within three (3) months from date ● Solo Parent ID ● School ID (currently
of application. ● NBI Clearance / ID enrolled)
2. Original Copy of the Social Case Study Report/ ● TIN ID ● Barangay ID
Certificate of Indigency or Eligibility issued by ● Passport ● Certification issued by the
the DSWD, PSWDO, CSWDO, MSWDO, or Medical ● UMID/GSIS/SSS ID hospital in case of newborns
Social Worker in the hospital, and addressed to the ● PhilHealth ID
OVP, or generic addressee (e.g., addressed to “your ● Voter’s Certification Alternative documents in
good office”, no addressee) ● Police Clearance / ID case of lack of valid ID due
3. Original/Certified Copy of Medical Records (e.g., ● 4Ps ID to fire, insurgency, or
Medical/Clinical Abstract, Medical Certificate) ● PRC ID calamity in the area:
4. Photocopy of one (1) valid Identification Card ● Postal ID

(ID) of: ● PWD ID 1. Justification from the PAD

a. Patient ● Senior Citizen ID Chief/SO Lead; and
b. Authorized representative if any ● Barangay/ LGU ID 2. Barangay Certification
● Philippine stating that: a) the person is a
5. Original Valid ID of Senior Citizen (SC)/
Persons with Disability (PWD) ID of the Identification System resident in the barangay; and
patient and Purchase Booklet. To be presented at (National ID) b) there was a
the time of claiming assistance in the Service fire/insurgency/calamity which
Provider to avail of the mandatory SC/PWD resulted to the
discounts. loss/unavailability of valid ID.

Per Case Type Requirements and Conditions

Chemotherapy/ Radiation 1. Treatment Protocol - Dated not more than three (3) months prior to the date
Therapy/ Brachytherapy of application
Hospitalization 1.1 If still admitted, the latest Statement of Account will be required. PhilHealth
Benefits and other mandatory discounts must already be deducted.
1.2 If discharged, the updated Statement of Account and Promissory Note will
be required.
Medicines/ Implant/ 1. Price Quotation from an OVP Service Provider or any service provider that is
Medical Equipment/ willing to accept Guarantee Letters.
Assistive Device 2. Prescription - Dated not more than three (3) months prior to the date of the
application.
3. Authorization Letter signed by the patient, if the patient will not be able to
personally receive the medicine/implant/medical equipment/assistive device.
Diagnostic Procedure/ For Dialysis Treatment:
Dialysis 1. Must have a Certification that PhilHealth
benefits have been exhausted
For Diagnostic Procedure:
1. Preferred in Gov’t Hospital, provide
Justification for private institutions (e.g.,
unavailability of procedure in Gov’t Hospital)
Wheelchair 1. Handwritten Personal Letter by the
patient addressed to the OVP/ Vice President
2. In lieu of medical records under Section 4.B.1, a certification from the
attending physician that the patient is in need of a wheelchair, or in case the
necessity is readily apparent, a photo of the patient will suffice.
The original documents shall be presented during the interview for validation. Processors/Verifiers may request for additional
supporting documents should the application require further validation and justification. Such additional documents may include, but
are not limited to, an Affidavit of Name Discrepancy for Correction of Entry, Police Report for Vehicular Accidents, Marriage Contract,
and etc.

11F, Robinsons Cybergate Plaza, EDSA cor. Pioneer St., Mandaluyong, 1550, Metro Manila
Tel. No. 8532-5942/ 8370-1719 vp@ovp.gov.ph