RAMIRO - ONLINE LOA REQUEST

HMO LOA REQUEST

LOAs are advised to be filed at least 3 days prior to your availment date. Please allow us at least 24 hours to process your request once submitted.

LAST NAME

FIRST NAME

MIDDLE NAME

BIRTH DATE

CONTACT NUMBER [ must be 11 characters ]

COMPANY / EMPLOYER

COMPANY ID NUMBER

HMO PROVIDER

HMO CARD NUMBER

TYPE OF REQUEST

CONSULTATION

OUTPATIENT (Laboratory, Diagnostic, Surgery)

UPLOAD DOCTOR'S REQUEST/REFERRAL

TYPE OF REQUEST is required.

DATE OF COLSULTATION / DATE OF LABORATORY PROCEDURE

NAME OF PREFFERED / EXISTING DOCTOR [ IF ANY ]

CHIEF COMPLAINT

BRIEF MEDICAL HISTORY

UPLOAD VALID ID

UPLOAD HMO ID

By clicking "Submit Request", you are allowing Ramiro Community Hospital to store your personal information and keep in touch with you if necessary.