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Annex A Medical Allowance Registration Form

The document is a Medical Allowance Registration Form for Department of Education personnel in Bacolod City, aimed at implementing DepEd Order No. 16, s. 2025. It includes a data privacy notice and requires personal information from employees to ensure secure handling of their data. The form also outlines the options for availing the medical allowance and requires certification of the accuracy of the provided information.

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KHARREN NABASA
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563 views2 pages

Annex A Medical Allowance Registration Form

The document is a Medical Allowance Registration Form for Department of Education personnel in Bacolod City, aimed at implementing DepEd Order No. 16, s. 2025. It includes a data privacy notice and requires personal information from employees to ensure secure handling of their data. The form also outlines the options for availing the medical allowance and requires certification of the accuracy of the provided information.

Uploaded by

KHARREN NABASA
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 A

Medical Allowance Registration Form


To ensure a seamless implementation of DepEd Order No. 16, s. 2025, which provides "Guidelines on
the Grant of Medical Allowance to the Department of Education Personnel," the Division of Bacolod City
will conduct this registration. Please complete this form. Thank you.

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 shall retain this
information over a period of ten years for the effective implementation and management of its
activities.

Employee Information

Full Name: ________________________________________________ Employee ID Number: ____________________


(Last Name, First Name, Middle Name)
Position/ Designation: _____________________________________ Office: ___________________________________
Original Date of Appointment (mm/dd/yyyy): _______________ Sex: ☐ Male ☐ Female
Date of Birth (mm/dd/yyyy) : ______________________________ Mobile Number: __________________________
DepEd Email Address: ________________________________________________________________________________
Region : ___________________________________________________ Division :_________________________________
School : ______________________________________________________________________________________________
Level: ☐ Elementary ☐ Junior High School-Implementing Unit
☐ Junior High School-Non-Implementing Unit ☐ Senior High School
Employment Status : ☐ Permanent ☐ Contractual
☐ Casual ☐ Substitute

Form of Availment

☐ Group (Agency Procurement)


☐ Individual
☐ Payroll Disbursement for availment of new/renewal of Individual HMO
☐ New ☐ Renewal
☐ Cash form for payment of medical expenses
Prerequisites:
 GIDA (Geographically Isolated and Disadvantaged Area) localities (either by
residency or assignment);
 Localities with no adequate HMO branch (either by residency or assignment); or
 Denied by HMO application

Certification
I hereby confirm that the information provided above is accurate and truthful. I agree to comply with
the terms and conditions outlined in the Guidelines on the Grant of Medical Allowance of DepEd
personnel, including the submission of required documents for verification and processing.
_____________________________________________________________________________________
_______
Printed Name & Signature:____________________________________ Date:_________________________

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