LOAs are advised to be filed at least 3 days prior to your availment date. Please allow us at least 24 hours to process your request once submitted.
DISCLAIMER: Please be reminded that requests made beyond *office hours will be processed on the next business day.
*Office Hours: 7:00AM - 7:00PM

NICC e-LOA Request

* Required

Patient Information

Last Name *

First Name *

Middle Name

Birthdate*

Sex *

Mobile Number (11-digit number)*

HMO Provider *

Company/Employer *

HMO Card Number*

Date of Availment*

Type of Request* Consultation
Laboratory/ Diagnostic Request

Name of Preferred / Existing Doctor(if any) [For Consultation only]

Chief Complaint:*

Attachments (*.jpg format) Valid ID
HMO ID
Doctor's Request

I hereby consent to the processing of my personal data for the selected purposes, and agree that NICC Doctors Hospital may collect, store, process and use the personal data I have provided.