Advance HMO Approval Request - AMSI Doctors Medical Center

Personal Information

Last Name *

First Name *

Middle Name

Age *

Date of Birth *

Gender *

Civil Status *

Mobile Number *

Email Address *

Medical Request Details

Request for Approval *

Consultation (Face-to-Face)

In-person physician consultation

Procedures / Diagnostic Examinations

Laboratory, Cardio-Pulmonary, Radiology

Requesting Physician

Chief Complaint / Diagnosis / Impression

HMO & Insurance Information

HMO *

HMO Account Number *

Company *

Health Card *

Click to Upload Health Card

Valid ID *

Click to Upload Valid ID

I certify that all information provided in this request is true, complete, and accurate. I hereby authorize AMSI Doctors Medical Center and its Advance HMO Approval System to process my personal and sensitive health information for the purpose of securing HMO authorization. This consent is given in full compliance with the Data Privacy Act of 2012 (Republic Act No. 10173) and its Implementing Rules and Regulations.

You will receive a approval confirmation via provided email or mobile number.