Republic of the Philippines )

City/Municipality of _____________ )
AFFIDAVIT
I, ______________________________________, of legal age, Filipino, single/married, with
business address at _________________________________________ after having been duly
sworn to in accordance with the law, hereby depose and say that:
1. That I am a Medical Doctor by profession and registered with the Bureau of Internal Revenue
RDO ______, ____________ City with Tax Identification No. _____________________.

2. That I am not currently holding clinic but has private patient at Tamola-Tan Medical Hospital,
Oroquieta City.

3. That on March 3, 2014, the Bureau of Internal Revenue released Revenue Regulation No. 4-
2014Guidelines and Policies for the Monitoring of Service fee of Professionals;

4. That I charge the following professional fees to my in-patient on Philhealth only and for non-
Philhealth is P500-P750 for the whole stay in the hospital.

5. That the manner of billing for in-patients is through the hospital;

6. That professional fees paid by Senior Citizens/PWDs are discounted by 20%;

7. That I am executing this affidavit to attest to the veracity of the foregoing facts and for all intents
and for whatever legal purpose it may serve.
IN WITNESS WHEREOF, I have hereunto set my hand this ___________ day of ___________, at
__________________________.
_______________________________
NAME
Affiant

SUBCRIBED AND SWORN to before me, in ____________, this __________ day of
_________________ with Community Tax Certificate No. _____________________ issued at
__________________ on _________________.
NOTARY PUBLIC
Doc No. _______
Page No. _______
Book No. _______
Series of 2014.
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