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Service Request Form: Reference Code

This document is a service request form from Candelaria Municipal Hospital seeking repair of errors in their final billing from the Knowledge Management and Information Technology Service. It provides contact information for Ona Monique Tapire of the hospital's office and describes the request for repair of errors acquired in their final billing. The form requires approval from the hospital chief and sections to note the actions taken, officers responsible, and approval from the supervisor.

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74 views1 page

Service Request Form: Reference Code

This document is a service request form from Candelaria Municipal Hospital seeking repair of errors in their final billing from the Knowledge Management and Information Technology Service. It provides contact information for Ona Monique Tapire of the hospital's office and describes the request for repair of errors acquired in their final billing. The form requires approval from the hospital chief and sections to note the actions taken, officers responsible, and approval from the supervisor.

Uploaded by

candelaria hospital
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

Knowledge Management and Information Technology Service Page No.

Page 1 of 1

Revision
0
No.
Service Request Form Effectivity: May 02, 2014

Reference Code: _______________


Date of Request (06/20/2018):

2) Name of Contact Person: Ona Monique Tapire


Last Name First Name Middle Name
3) Office: Candelaria Municipal Hospital
4) Address: Brgy. Masin Norte, Candelaria Quezon
5) Landline: (042) 585-8327 6) Fax No. 7) Mobile No. 09466269364
8) DESCRIPTION OF REQUEST: (Please clearly write down the details of the request.)

Request for the repair of errors

Error acquired in final billing

9. APPROVED BY: __Wennie P. Alcantara__________ June 20, 2018


Name & Signature of Head of Office Date Signed
Chief Of Hospital___________
Position

(For Knowledge Management and Information Technology Service only)

10. Date Received (mm/dd/yyyy): ___/___/______ 11. Time Received (hh:mm) ____:____ AM PM
12. ACTIONS TAKEN: (Use separate sheet if necessary)
DATE TIME ACTION TAKEN ACTION OFFICER SIGNATURE
(a) (b) (c) (d) (e)

13. NOTED BY: 14. 15.

Name and Signature of Supervisor Position Date Signed


DOH-KMITS-SRF

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