HMO - LOA request | Exact Check Diagnostic Center

Online HMO - LOA Request

Our online HMO - LOA request form is designed to provide assistance for a more convenient way to request a LOA (Letter of Authority) for outpatient utilization of our services.

Please note that you will be required to fill in all your details, upload a photo of your HMO card, one valid government ID, and the RX / request form from your accredited physician.

Once you submit your details, please expect 1-2 days of processing. Upon approval, we will text or email you to confirm the approval of your LOA and appointment schedule for the requested procedures. The LOA request is valid for 2 days.

Patient Details

Full Name (Same as name in government ID.) *

Date of Birth *

Month

Day

Year

Gender *

Male

Female

Mobile Number *

Email Address *

HMO/LOA Request:

Type of LOA Request *

Consultation

Diagnostic Test

Others (please specify)

Provider *

HMO / Insurance Account Number *

Company *

Requested Date of Availment *

Month

Day

Year

Chief Complaint / Diagnosis *

Attending Physician *

Attachments (Required):

RX / request from accredited doctor *

Files must be less than 500 KB.
Allowed file types: jpg jpeg png pdf doc docx.

Valid HMO Card *

Files must be less than 500 KB.
Allowed file types: jpg jpeg png doc docx.

Valid Government ID (Driver's license, Passport, PCR license, SSS, UMID, etc.) *

Files must be less than 500 KB.
Allowed file types: jpg jpeg png pdf doc docx.

Exact Check Diagnostic Center, Inc.

We pride ourselves to have a fully automated, computerized laboratory providing routine and special laboratory procedures in the field of Clinical Chemistry, Hematology, Clinical Microscopy Parasitology, Immunology, Serology, Surgical Pathology and Drug Testing. We also offer radiology services such as digital X-ray, CT – Computed Tomography scan, Mammography and Fibroscan. Our Cardiology tests include Treadmill Stress Tests, ECG, Holter and BP Monitoring as well as 2D Echocardiogram.