General Requirements
- Original Copy of Medical Application Form. Dated and signed within three (3) months from date of application.
- Original Copy of the Social Case Study Report/Certificate of Indigency or Eligibility issued by the DSWD, PSWDO, CSWDO, MSWDO, of Medical Social Worker in the hospital, and addressed to the Provincial Governor’s Office (PGO).
- Original/Certificate Copy of Medical Records (e.g., Medical/Clinical Abstract, Medical Certificate)
- Photocopy of one (1) valid Identification Card (ID) of:
- Patient
- Authorized representative in any
List of Valid IDs
- Driver’s Liscense
- Solo Parent ID
- NBI Clearance / ID
- TIN ID
- Passport
- UMID/GSIS/SSS ID
- PhilHealth ID
- Voter’s Certification
- Police Clearance / ID
- 4Ps ID
- PRC ID
- Postal ID
- PWD ID
- Senior Citizen ID
- Barangay/LGU ID
- Philippine Identification System (National ID)
Alternative IDs for Minors
- Registered Birth Certificate
- School ID (currently enrolled)
- Barangay ID
- Certifications issued by the hospital in case of newborns
| Per Case Type | Requirements and Conditions |
| Chemotherapy/ Radiation/ Therapy/ Brachytherapy/ Physical/ Speech/ Occupational/ Behavioral/ Cognitive Therapy | 1. Photocopy of Treatment Protocol – With cost breakdown, issued by the attending Physician. Dated not more than three (3) months prior to the date of application. |
| Hospitalization | 1. If still admitted, photocopy of the latest Statement of Account will be required. PhilHealth benefits and other mandatory discounts must already be deducted. 2. If discharged photocopy of the updated statement of Account and Promissory note will be required. |
| Medicines/ Implant/ Medical Equipment/ Assistive Device | 1. Photocopy/Original Price Quotation from RAC Service Provider. 2. Photocopy of Prescription – Dated not more than three (3) months prior to the date of application. 3. Original Authorization Letter signed by the patient, if the patient will not be able to personally receive the medicine/implant/medical equipment/ assistive device. |
| Dialysis | 1. Must have the original copy of Certification that PhilHealth benefits have been exhausted. 2. Original/Photocopy of Price Quotation from a RAC Service Provider. |
| Diagnostic Procedure | 1. Preferably to be performed in a government hospital provide original copy of Justification for private institutions (e.g., unavailability of procedure in Gov’t Hospital). 2. Original/Photocopy of Price Quotation from a RAC Service Provider. |
| Wheelchair | 1. Handwritten Personal Letter by the patient addressed to PGO/Governor. 2. In lieu of medical records under Section 4.B.1, a certification from 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. |
