Health and welfare support

Medical Assistance Application

Request medical assistance by providing the patient, medical condition, and supporting document details below.

Online submission Secure information

Application details

Tell us about your request

Required fields

Only active members are eligible. Ensure medical records and receipts are clear, complete, and ready to upload.

I. PERSONAL INFORMATION

Please fill out the following information.

Date of Filing^*

Membership / Employee ID Number:^*

Service:

Unit^*

First Name:^*

Middle Name:

Last Name:^*

Email Address:

II. MEDICAL CONDITION

Please provide details about the medical condition.

Medical Condition: (Please check one)^*

Dialysis Treatment

Cancer Treatment

Surgical Procedure

Work-Related Injury

Medicine & Maintenance Allowance

Date of Diagnosis / Incident / Purchase:^*

Hospital or Facility Name: (if applicable)

Amount of Medical Expenses: ₱^*

III. REQUIRED ATTACHMENTS

Submit copies along with the application form.

ATTACHMENTS:^*

Recent Medical Certificate

Valid ID of the applicant

Supporting Documents (if applicable)

IV. DECLARATION AND AGREEMENT:

Please read the following declaration carefully and tick the checkbox below.

I hereby certify that the information provided in this form is true and correct. I also understand that submitting falsified information may result in the rejection of my application and potential disciplinary action. I also agree to comply with the rules and requirements set by the PHC Employees Association - Alliance of Health Workers regarding this assistance program.^*

Date of Application:^*

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Review each entry before submitting. Keep digital copies of any required documents ready for upload.

Submitting your application

Medical Assistance Application