PHILIPPINE CHARITY (75) SWEEPSTAKES OFFICE INDIVIDUAL MEDICAL ASSISTANCE PROGRAM (IMAI The IMAP was conceptualized in 1993 to attend to the financial needs of all individuals with health-related problems through the provision of financial assistance. A guarantee letter is issued to the hospital or partner health facility which assumes the obligation of a specific amount due from the client for the services rendered. OBJECTIVE ‘The program aims to provide timely and responsive financial assistance to individuals with health-related needs. a CRITERIA All Filipino patients who request for assistance, either personally or through a representative, ona health-related concern, including: © Those confined in any health facility; © Those receiving health care management as outpatients; and * Those seeking management in foreign countries, provided that no health facility within the Philippines is capable of providing such procedure. HEALTH SERVICES COVERAGE 1. Confinement — currenily admitted or discharged acknowledged by the health facility promissory note duly 2, Dialysis, such as, but not limited to: © Hemodialysis * Peritoneal (Continuous Ambulatory Peritoneal Dialysis (CAPD]) 3. Cancer Treatment, such as, but not limited to: * Chemotherapy * Oral (Hormonal) * Intravenous © Radiation Therapy + Extemal Beam Radiation Therapy (EBRT) = Cobalt Therapy = Linear Acceleration — Tomotherapy — Intensive Modulation Radiation Therapy (IMRT) * Brachytherapy * Radioactive Iodine (RAI) * Stereotactic Radiosurgery/Gamma Knife 4, Medicines, such as, but not limited to: © Anti-tabies Factor 8 and 9 Psychiatric Post-transplant/post-operative Antibiotics Intravenous Immunogiob (IVIG) NDIVIDUAL MEDICAL ASSISTANCE PROGRAM (IMAP) 3. Surgical supplies 4, Implant, such as, but not Limited to: * Bone © Cochlear # 5. Laboratory/Diagnostic Procedures 6. Devices, such as, but not limited to: 6.1 Medical Devices © Pacemaker device * Septal occluder * Percutaneous Coronary Intervention (PCI) devices 6.2 Assistive Devices © Hearing Aid + Bone Anchored Hearing Aid (BAHA) © Wheelchair © Prosthesis such as Leg, Arm or Eye Pulmonary Apparatus ~ Rental of Ventilator/Respirator 7, Non- and Minimally Invasive Procedures, such as, but not limited to: + Extracorporeal Shock Wave Lithotripsy (ES WL) E © Laparoscopic surgery + Endoscopic procedures Giew: ETC 8, Transplant Procedures, such as, but not limited to: «Kidney Transplantation Packages = For living related transplant package (with Monoclonal induction) = For living related transplant package (Non monoclonal) = Cadaver (Deceased Donor) transplant package © Liver Transplant Package fo 9. Cardio Procedures C ‘* Pacemaker surgery ~ © Congenital Heart Surgery 4 = ASD, PDA, VSD sy Coronary Artery Bypass Graft Z Aneurensugery ae Peripheral bypass surgery Percutaneous Coronary Intervention (Angioplasty) Diagnostic procedures: * Coronary Angiogram = Cardiac Catheterization 10. Rehabilitative Therapy (Physical/Occupational/Speech Therapy) lbs > a = = ya DOCUMENTARY REQUIREMENTS Nature of Request Hy Documentary Requirements ge ¢ : z= inst balvaiglid : Waeetg eed geltaal| ELE EES|P E422 mms PEE] 1. Duly accomplished PCSO IMAP Application “1. sa RS Rn Ee Be a a a a Ea Ee Form 2. Original/Certified True Copy of the Updated Clinical Abstract duly signed by the attending physician with License Number * For Wheelchair requests, Medical Certification will suffice 3. Valid 1D (Patient and Representative) Any Government issued identification card, such as: Passport Drivers License SIS eCard oe vivi[v|elvlelelelelelelel| dele Voter's 1D Phil Health 1D Senior Citizen's 1D DsWO-4P's 1D + Company 10 + student 0 * Authorization Letter from patient in cases where there is no immediate relative available for interview “4. Original copy of the Statement of Account/ Hospital Bill duly signed by the Billing Officer/Credit Supervisor ¥ * For pay section patients, must be duty stamped bearing the phrase “For PCSO Assistance” 53. Endorsement from the Medical Social Services | 7 ‘of the health facility (For charity/service patients) 6. Endorsement/Certificate of Acceptance of PCSO Guarantee Letter * Shall no longer be required in the case of facilities where the PCSO Desk has been established 7._ Official quotation from service provider v v v v 7 8. Official quotation with breakdown of v ‘expenses 9._ Official sealed quotations from 3 suppliers v Z| ANI 10, Relevant laboratory result v7 77 11. Photocopy of Histopath/Biopsy report y) * For chemotherapy requests 12, Audiological Evaluation Report signed by a 7 licensed Audiologist 13. Cross-matching results i 414. Original prescription duly signed by physician e with License Number 15. Copy of the physician's order with implant er specification 16, Laboratory request duly signed by physician 2 with License Number T7, Progress Notes ftom the doctor/oncologist ey 7 * For chemotherapy requests ‘One (2) whole-body picture 19. Certification from Dialysis center v 20. Certification of patient's inclusion in ‘transplant program from authorized ¥ representative of NTI if applicable 21, Relevant PhilHealth tracking number E certification. 22, Police Report — For medico-legal cases ¥ % |