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Medical Allowance Annex B

The document is an Individual Cash Claim Form from the Department of Education, which includes a Data Privacy Notice outlining the handling of personal data in compliance with the Data Privacy Act of 2012. It requires employment information, pre-requisite requirements, and details of medical expenses incurred, along with a certification statement for accuracy. The form emphasizes the protection of personal data and the consequences of submitting false claims.

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Angelica Libuna
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5K views1 page

Medical Allowance Annex B

The document is an Individual Cash Claim Form from the Department of Education, which includes a Data Privacy Notice outlining the handling of personal data in compliance with the Data Privacy Act of 2012. It requires employment information, pre-requisite requirements, and details of medical expenses incurred, along with a certification statement for accuracy. The form emphasizes the protection of personal data and the consequences of submitting false claims.

Uploaded by

Angelica Libuna
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Annex B

Individual Cash Claim Form

Data Privacy Notice: The Department of Education recognizes its responsibility under the
Republic Act No. 10173, otherwise known as the Data Privacy Act of 2012, with respect to the
data they collect, record, organize, update, use, consolidate or destruct from their personnel. The
personal data obtained from this form is entered and stored within the organization’s authorized
information and communications system and will only be accessed by authorized personnel. The
organization has instituted appropriate technical and physical security measures to ensure the
protection of personal data.

Furthermore, the information collected and restored in the portal shall only be used for the
purposes of this activity. DepEd shall not disclose any personal information without consent and
shall retain this information over a period of (10) ten years for the effective implementation and
management of its activities.

Section 1: Employment Information


Full name: ____________________________________________________
Employee ID number: _________________________________________
Position/Designation: _________________________________________
Office: ________________________________________________________
Service Duration: (From-To): __________________________________

Sex: _______ Date of Birth (dd/mm/yyyy): ______________________


Mobile Number: _________________________
DepEd Email Address: ____________________________________

For teaching personnel


Region: __________________________________
Division: _________________________________
School: ________________________________________________

Employment Status: Permanent Contractual


Casual Substitute

Section 2: Pre-requisite Requirements.


Supported with applicable documents, check any of the following conditions below that applies.
GIDA Certification
Certification of area with no HMO
Letter or email from HMO denying the application

Section 3: Details of Medical Expenses Incurred


Name of Medical Address Date(s) of Medical
Provider/Facility Consultation/Service

Description of Expense Amount (in PHP) Receipt No./Reference


Consultation Fee
Laboratory/Diagnostic Tests
Medication
Hospitalization
Other (please specify)
Total Amount
Please attach original receipts

Section 3: Certification
I, the undersigned, hereby certify that the information provided in this claim form is true and
correct to the best of my knowledge, and the medical expenses listed above were incurred for
legitimate medical purposes. I understand that submission of false claims shall be subject to
disciplinary action and other legal consequences as determined necessary by the Department of
Education.

Employee’s Signature: _________________________ Date: _____________________________

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