The Self Declaration Form For Medical Reimbursement is a crucial document used in the Philippine business environment to facilitate the reimbursement of medical expenses to employees. This form is designed in accordance with Philippine labor laws, the Universal Health Care Act, and PhilHealth regulations, serving as an official record of medical expenses incurred and a formal request for reimbursement. It is typically used when employees seek reimbursement for out-of-pocket medical expenses for themselves or their qualified dependents. The document includes detailed information about the medical treatment, associated costs, and requires supporting documentation such as official receipts and medical certificates. It also incorporates necessary privacy protections under the Data Privacy Act of 2012, as it handles sensitive personal and medical information.
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1. Declaration Header: Title of the form and organization details
2. Employee Information: Full name, employee ID, department, contact details, and position of the declaring employee
3. Patient Information: Details of the patient (self/dependent) including full name, relationship to employee, and date of birth
4. Medical Expense Details: Itemized list of medical expenses including date of service, healthcare provider, nature of medical service, and amount
5. Payment Information: Details of how the medical expenses were paid, including receipts reference numbers
6. Total Claim Amount: Total amount being claimed for reimbursement
7. Declaration Statement: Formal statement declaring the truthfulness of the information provided and understanding of consequences for false declarations
8. Signature Block: Space for employee signature, date, and witness signature if required
1. Insurance Coverage Declaration: Section to declare if expenses are covered by other insurance policies - include when employee has multiple insurance coverage
2. Dependent Authorization: Authorization section when claim is for a dependent's medical expenses
3. Emergency Treatment Declaration: Special section for emergency treatment cases where prior approval wasn't possible
4. Chronic Condition Details: Additional section for ongoing treatment of chronic conditions
5. Foreign Treatment Declaration: Special section when medical treatment was received outside the Philippines
1. Receipt Checklist: Checklist of required supporting documents and receipts
2. Medical Certificate: Attached medical certificate from attending physician
3. Prescription Details: List of prescribed medications and treatments
4. PhilHealth Claim Form: Attached PhilHealth claim form if applicable
5. Proof of Payment: Copies of official receipts, payment confirmations, and other payment documentation
Relevant legal definitions
Clauses
Relevant Industries
Healthcare
Insurance
Banking and Financial Services
Manufacturing
Information Technology
Business Process Outsourcing
Education
Retail
Construction
Transportation
Hospitality
Professional Services
Government Services
Non-Profit Organizations
Relevant Teams
Human Resources
Finance
Payroll
Compliance
Employee Relations
Administration
Legal
Internal Audit
Relevant Roles
Human Resources Manager
HR Benefits Specialist
Compensation and Benefits Manager
Finance Manager
Accounts Payable Specialist
Payroll Manager
HR Director
Finance Director
Compliance Officer
Employee Relations Manager
HR Administrator
Benefits Administrator
Finance Controller
Administrative Officer
HR Business Partner
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