Get PH SSS MED-01688 2022-2024
Republic of the Philippines SOCIAL SECURITY SYSTEM MEDICAL CERTIFICATE SSS FORM MMD - 102 1. EMPLOYEE S GENERAL DATA NAME Last First M.I. AGE SEX CIVIL STATUS OCCUPATION DATE EXAMINED/ATTENDED To From 2. BRIEF CLINICAL HISTORY AND PRESENT PHYSICAL FINDINGS Attach extra sheet if needed 3. X-RAY LABORATORY AND/OR SPECIAL DIAGNOSTIC EXAMINATION Attach extra sheet if needed 4. FINAL DIAGNOSIS 5. EXACT DATE OF DISABILITY 6. KIND OF SURGICAL OPERATION PERFORMED IF ANY If claim is for disability attach operating room record 7. DATE OF OPERATION 8. PERIOD OF MEDICAL ATTENDANCE/ TREATMENT/ACTUAL SICKNESS CONVALESCING OR RECUPERATION PERIOD PLACE OR PLACES WHERE THE PATIENT WAS CONFINED DURING MY MEDICAL ATTENDANCE AND/OR TREATMENT PLACE/S OF CONFINEMENT DATE FROM TO 9. OTHER REMARKS PURSUANT TO SECTION 28 OF THE SOCIAL SECURITY LAW AS AMENDED ANYONE WHO RESORTS TO MISREPRESENTATION OR CONCEALMENT OF A MATERIAL FACT OR WHO IS A PARTY THERETO FOR THE PURPOSE OF CAUSING ANY PAYMENT OF FRAUDULENT CLAIM OR BENEFIT UNDER THE SAID LAW SHALL SUFFER THE PENALTIES OF FINE OR IMPRISONMENT OR BOTH. I HEREBY WARRANT THAT I HAVE THOROUGHLY EXAMINED THE HEREIN PATIENT/CLAIMANT AND THAT THE FOREGOING INFORMATION ARE TRUE AND CORRECT. PHYSICIAN S SIGNATURE OVER PRINTED NAME ADDRESS LICENSE/CERTIFICATE NO. DATE OF ACCOMPLISHMENT STATEMENT OF WAIVER I HEREBY WAIVE ANY RIGHT OR PRIVILEGE I MAY HAVE ON ALL INFORMATION PERTAINING TO MY MEDICAL HISTORY AND I CONSENT TO ALLOW SSS TO EXAMINE ALL MY MEDICAL RECORDS* RIGHT OR LEFT THUMBPRINT OF PATIENT/CLAIMANT IF ILLITERATE OR UNABLE TO WRITE Internet Edition 7/2000.
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