Scribd
Upload
1K views2 pages

Individual Cash Claim Form Annex B

The document is an Individual Cash Claim Form from the Department of Education, which includes a Data Privacy Notice outlining the handling and protection of personal data in accordance with the Data Privacy Act of 2012. It requires employees to provide personal information, details of medical expenses incurred, and necessary supporting documents. The form also includes a certification section where the employee attests to the accuracy of the information provided and acknowledges the consequences of submitting false claims.

Uploaded by

Alexis Mae Dayondon Cabilis
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF or read online on Scribd
1K views2 pages

Individual Cash Claim Form Annex B

The document is an Individual Cash Claim Form from the Department of Education, which includes a Data Privacy Notice outlining the handling and protection of personal data in accordance with the Data Privacy Act of 2012. It requires employees to provide personal information, details of medical expenses incurred, and necessary supporting documents. The form also includes a certification section where the employee attests to the accuracy of the information provided and acknowledges the consequences of submitting false claims.

Uploaded by

Alexis Mae Dayondon Cabilis
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF or read online on Scribd
You are on page 1/ 2
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 stored in the portal shall only be used for the purposes of this activity. DepEd shall not disclose any personal information without consent and shali retain this information over a period of ten years for the effective implementation and management of its activities. Section 1: Employee Information Full Name: Employee ID Numbe Position /Designation: Office: Service Duration: (From — To): Sex: _ Date of Birth (dd/mm/yyyy): Mobile Number: DepEd Email Address: For teaching personnel Region: C) Permanent O Contractual O Casual O Substitute Section 2: Pre-requisite Requirements. Supported with applicable documents, check any of the following condition below that applies. Cl GIDA Certification C Certification of area with no HMO C 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 Please add rows as necessary) Description of Expense ‘Amount (in PHP) Receipt No./Reference Consultation Fee Laboratory /Diagnostic Tesis Medication. Hospitalization Others (please specify) Total Amount Please attach original receipts Section 3: Certification 1, 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:

You might also like