Republic of the Philippines )
City/Municipality
of _____________ )
AFFIDAVIT
I, ________________ , of legal age, Filipino, single,
with business address at Suklayin, Baler, Aurora 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 __, Municipality of _____________ with Tax Identification No. ____________________.
2.
That
I am currently holding clinic at ____________________________.
3.
That
on March 3, 2014, the Bureau of Internal Revenue released Revenue Regulation
No. 4-2014 Guidelines and Policies for the Monitoring of Service fee of
Professionals;
4.
That
I charge the following professional fees to my patient:
a)
Consultation
fee – Php XXX
b)
Surgical
cases are based on relative value score (RVS) x
c)
Medical
cases are based on room rates x
The
above-rates would vary depending on the classification, relation of patient,
difficulty of cases, length of service, and complications arising from
condition.
5.
That
the manner of billing for in-patients is through the hospital; while for
out-patient is through the clinic.
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. _______
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