PHILIPPINE HEALTH INSURANCE CORPORATION

QUARTERLY REPORT FORM

NAME OF PCB PROVIDER

HEALTH FACILITY DATA
SUMMARY OF BENEFITS AVAILMENT (Members and Dependents)

I. Covered Period IV. Obligated Services

From October 2017
TARGET ACCOMPLISHMENT
To December 2017 OBLIGATED SERVICES
(for the quarter) (number)
Primary Preventive Services
II. PCB Participation No. 1. BP Measurement 0 218
Hypertensive 0 27

III. Municipality/City/Province
Nonhypertensive 0 193
2. Periodic Clinical Breast Examination 0 25
3. Visual Inspection with Acetic Acid 0 0

No. of Members/Dependents VII. Medicines Given No. of Members

VI. BENEFITS/SERVICES PROVIDED
V. Members and Dependents Served Given Referred (Generic Name) Dependents
Male Female TOTAL Primary Preventive Services M D M D I. Asthma M D
1. Consultation 92 213 AMBROXOL 30 mg TABLET 0 2
Members: 66 26 92
2. Visual inspection with acetic acid 0 0 II. AGE with no or mild dehydartion
Dependents: 63 150 213 3. Regular BP measurements 72 135 Dicycloverine 10mg. as hydrochloride 0 1
TOTAL 129 176 305 4. Breastfeeding program education 2 10 Metronidazole 125mg/5mL
0 4
5. Periodic clinical breast examination 1 24 suspension, 60mL
6. Counselling for lifestyle modification 50 50 Cotrimoxazole 400mg 0 1
7. Counceling for smoking cessation 28 23 COTRIMOXAZOLE 800MG 0 2
8. Body Measurements 26 50 Cefalexin 500mg cap 0 1
VIII. 10 Common Number of III. URTI/Pneumonia (minimal & low risk)
Illnesses (Morbidity) Cases 9. Digital rectal examination 0 0
Diagnostics Examinations Ascorbic Acid 500mg. tablet 1 0
1. Complete blood count (CBC) 3 2 0 0 Cotrimoxazole 800mg 0 1
Paracetamol 125mg Syrup 1 0
2. Urinalysis 5 11 0 0
Cotrimoxazole 400mg 1 2
3. Fecalysis 0 3 0 0
Paracetamol 500 mg tab 1 1
4. Sputum Microscopy 1 9 0 0
COTRIMOXAZOLE 200/40mg
Type II diabetes mellitus, 5. Fasting blood sugar (FBS) 14 6 0 0 0 1
3 Suspension 60ml
non-insulin-requiring
6. Lipid profile 0 0 0 0 COTRIMOXAZOLE 800MG 2 3
7. Chest x-ray 1 5 0 0 IV. UTI
Ciprofloxacin 500mg 0 6
V. Nebulisation Services