Republic of the Philippines. SOCIAL SECURITY SYSTEM MATERNITY BENEFIT REIMBURSEMENT APPLICATION SIC 01262 (12.2015) N "AND 1S NOT FOR SALE, THIS CAN ALSO BE DOWNLOADED THRU THE SSS WEBSITE AT worw-sen.govph- ITLERSE READ THE INSTRUCTIONS AND REMINDER AT THE BACK BEFORE FLING OUT THIS FORM PRINT ALL NFORNATION IN CAPITAL LETTERS AND USE. BLACK. INK ONLY, PART 1- TO BE FILLED OUT BY MEMBER 7 PERSONAL DATA SS TONBER COMMON REFERENCE WONBER seams [BATE OF BIRTH ancarrny | TARIGENTIIORTION NUMBER any pA Pe eS Ep i he aa Lae wera Lt [SEAL RORERS TERR TRISHA SRT TERE RTI Ss SORTS Sa Fe Ee oO fan HECEPRONE REA sc NOT ETCET TOE WOR ERC AOORESS Yo a] fee Df STaRT OF WATERIITY ENE OATE OF DELVERTT ROSS Tet Saari eT SER OF PREGRNCES I Normst 5] Miscariage Ectopic (Operates) 1 cavsarean 1 Wile C1 Ectopic (Unoperted) 'B CERTIFICATION Tosa hat {2 The information povided in is form are true and correct; and actualy recived he amount of banat ue a incites Par I-8 of hs orm, (Do not sign if amount ls not actualy advanced) PRINTED NAME ‘SENATORE DATE member cannot sin, ax fingerprints. Please rsd instruction No.6 of he form Below ao tho witnesses to fingrprinting 0 PRINTED NAME ‘SIGNATURE DATE [ADDRESS & CONTACT NUMBER ‘PRINTED NAME a [ADDRESS & CONTACT NUMBER FIGHT THUD, RIGHT INDEX PART Il- TO BE FILLED OUT BY EMPLOYER "A EMPLOYER DATA [ 1D vousehts [EMAL ADDRESS WEBSITE yon auinescounoreR CONPUTATION [DAILY MATERNITY ALLOWANCE INOWGER OF DAYS [TOTAL WONTHLY SALARY CRED [AVOUNT OF BENEFIT DUE 2 2 2 T_CERTFICATION Teaniy at {The eaten provided in this form are rus and earect The qualiting contrbutons of member were paid porto the date of eliverymiscariageprocedue, and ‘© The ameunt of benef ue a indicated above was aovanced tothe employe PRINTED NAME SCRATURE POSTON TLE DATE veTen — ll Wa MATERNITY BENEFIT REIMBURSEMENT APPLICATION — ACKNOWLEDGEMENT STUB [SS NUWBERICONMOH REFERENCE NO ray RANE TTY RT eT Oo Cd [bare oF DeLVERYT RECENEDBY luiscaRrincerPRoceDURE (ele ‘SIGNATURE OVER PRINTED NAVE, DATES THE BRANCHINSTRUCTIONS Fill out this form in one (1) copy. ‘Aways indicate “NIA or ‘Not Applicable’ ifthe required data is not applicable. ‘Afi intials on aterations/erasues in this form. \Wete SS Number and name of member inal the supporting documents submited Present valid identification card/s or documenUs. Refer to the attached “Uist of Fle’s Val Identification (1D) Cards/Documents” | member cannot sign, there should be two (2) witnesses to fingerprinting, One (1) winess is the employer representatvelcompany representative andthe other one 1) could be any person. ‘Submit this form to the nearest SSS branch office together withthe following supporting documents, whichever is applicable. {8 Materity Notfeation (MN) duly received by SSS prior to delivery! miscamagelprocedure or "Maternity Notification Submission Confirmation” (¢ fled thru the SSS Website or SSIT), Note: MN isnot require ifthe member delveredivas confined in a hospital duly censed by the Department of Heath, b. Required Documents Present the orignalicertined true copy and submit the photocopy of the folowing, whichever is applicable ba ‘© Chis bith or fetal death certificate duly registered with the Loca Givi Registrar (LCR) 2 For Caesarean Delivery * Chie bith or fetal death certificate duly registred with the LCR: ana + Any of the following documents issued by the hospital indicating the type of delivery ‘Operating Room Record (ORR) ‘Surgical Memorandum Discharge Summary Report Medicelinical Abstract, Delivery Report Detailed Invoice showing caesarean delvery charges, for eliveries abroad only Rana 3 For Compete Miscarriage * Obstetrical History indicating the numberof pregnancies duly cetiied by attending physician with his/her. Professional Medical Ueense Number wth ited name and senate + Any ofthe following "Pregnancy test before and ater miscarage Unrasound report indieating proot of pregnancy ¥ Medical Certieate issued by attending physician on the ‘Greumstances of pregnancy 4 For Incomplete Miscarriage bs. ‘+ Obstetrical History indicating the number of pregnancies duly cetiied by attending physician with hisiner Professional Medical License Number with printed name and signature; ang + Any ofthe folowing Certified true copy of Hospital Medical record's Dilation & Curetage (D & C) report Histopathological report Pregnancy test before and after miscariage Utrasound report Indicating proot of pregnancy sans or Ectopic Presnancy ‘© Obstetrical History indicating the number of pregnancies duly cetiied by attending physician with hisiher Professional Medical License Number with printed name and signature; and «+ Any ofthe folowing: Certified tre copy of HospitalMedical record's Cortfied tre copy of ORR Histopathological report Pregnancy test before and after miscarriage RAK 16 EorHydatidform Mole ‘Allof the following + Obstetrical History indicating the number of pregnancies duly certified by atlonding physician with hishher Professional Megical License number wih printed name and signature + D&Creport + Histophathological report, Note: The Medical Specialist may require other documents necessary for the evaluation of the claim (for miscariagel ectopiciH-Mole cases) For _delveriesimiscarriages/procedures that _ happened ‘broad, documents issued by foreign country should be wih Englsh translation and duly authenticated by the Philippine Embass/Gonsite Ofc or duyntazd by rotary pub Inhost county ‘The signatory in Part ILC of this form shall be the employers authorized signatory refleced in the Employer Specimen Signature Card (SS Form L501). REMINDER Full amount of the maternity beneft shall be advanced by the employer within thy (30) days from the date of fling mater leave application 2. Verification of status of claim may be mat ‘thru the SSS Webste at ww.ss5.g0v.ph or contact our Call Center at $20-6448 to 55 WARNING ANY PERSON WHO MAKES ANY FALSE STATEMENT IN THIS APPLICATION OR SUBMITS ANY FALSIFIED DOCUMENTS IN CONNECTION WITH THE ‘APPLICATION WITH THE SSS SHALL BE LIABLE CRIMINALLY UNDER SECTION 28 OF RA 8282 OR UNDER PERTINENT PROVISION OF REVISED PENAL CODE.[SS NOWEER INANE OF MENEER TTT FRET TOE ™ PARTI. TO BE FRLED OUT BY SSS TA. BRANCH OFFICE [SCREENING AND RECENING RESULTS (NITIAL FILNG) REMARKS to's Presented ty er) ACR Gard) Company authorization ltr and company ID Cisscard CO] Valdi0 Caras ec Decumen’s C} None JFor Accomplishment) Complete) Incomplete ee emer) JoccumortsSubmttes C) completo) Incomplete (28 remars) etbaty Resut Causes CF) Not uattedDenieannin discrepancies (ee rms) JScREENED ANO RECEIVED BY ‘SIGNATURE OVER PRINTED NAME ‘DATE me DATE RETURNED, [SCREENING AND RECEIVING RESULTS (RE-FILED CLAM) REMARKS cia accertes cian no cceped (sera) Receiven By “SIGNATURE OVER PRINTED NAME ‘DATE RETURNED TE MEDICAL EVALUATION SECTION (FOR MISCARRIAGE CASES) FCINESS CODE ]AGNOSTS RECOMMENDATION Creproved No.of Cy 1 benies msenoe pregnancy ot compensable C1 Rewmes or Compionce 1D Based on nistopth rau regrancy not confmed 1 svomt0 4 Creat 1D B2e0d on uvasound resut, pregnancy net conte BSubmt Operating Room Recor (ORR) OO Remar 1B _sutrithistopstlogcaresut 1 Penn BSubmt pregnancy resut before and ar miscarige) Formosa option Submit utrasound rest For document verigcaton Submit cole 08 History issued by tending physician Fortegscpion Ferner & resent SS Cardo Va 0 Cards Documents Remarks OF emcee RECEIVED By (NTTIAL FLING) EVALUATED BY ‘IGRATORE OVER PRINTED NAWE DATE ‘IGRATURE OVER PRINTED NAME DATE RECEIVED By (RE-FLED CLAM) JEVALUATED BY SIGNATURE OVER PRINTED RANE DATE 'SIGHATURE OVER PRINTED NAME DATE ©. PROCESSING CENTER RECEVED BY (NTL FLING) PROCESSING RESUUTS JPROCESSED AND ENCODED BY “SIGNATURE OVER PRINTED NAME DATE ‘SIGNATURE OVER PRINTED NAVE DATE Review Resucr ISONCORRED BY 1D Aoproved TD Repcted a Denes Jreveweo ay “SIGNATURE OVER PRINTED NAME DATE ‘SHEMATURE OVER PRINTED NAME Date RECEVED BY REFIED CHAM PROCESSING RESULT lPROCESSED AND ENCODED BY ‘SIGNATURE OVER PRINTED NAME DATE ‘SIGNATURE OVER PRINTED NAME DATE FREveW Resor [CONCURRED BY I Apes TD Races 5 Denes JrevieweD by ‘SGHATORE OVER PRINTED NAME DATE ‘SIGNATIRE OVER PRINTED NANE DATE