HMO Request for Approval Imus HMO Accredited Cards Daet HMO Accredited Cards Batobalani HMO Accredited Cards Select VIMCDCI Branch *Please select an optionImusBatobalaniDaetAppointment Date *Please select date at least 1 day before the visit*HMO Information --Company Name *Upload HMO Card *Drag and Drop (or) Choose FilesFor Beneficiary; please include the Principal Card.*Personal Information --Birth Date *Contact Number *Upload Government Issued ID *Choose FileNo file chosenDelete uploaded fileValid ID with Birth Date Info.Email Address **Doctor's Information --Doctor's Full Name *Doctor's Specialization *Doctor's Clinic/Hospital Affilation *Upload Doctor's RequestChoose FileNo file chosenDelete uploaded fileDoctor's Diagnosis *Other Symptoms/Complains*Others Information --Upload Other DocumentsDrag and Drop (or) Choose FilesFor vehicular accident/other accidents; may need a Police/Barangay Incident Reports and driver's license of the driver who where involved in the accident.I hereby certify that the information provided in this form is true and correct to the best of my knowledge.I hereby acknowledge that i have read, understand and agree to VIMCDCI Privacy Policy. SubmitPlease do not fill in this field.
