NCIA - Online Helpdesk

LOA Request Form

Choose Provider:

Company Code:

Name of Principal

Patient's Name (principal/dependent)

Birthday

HMO Card Number

Name of Preferred Hospital/Clinic:

Requesting Doctor

Date of Availment

Type of Availment

Chief complaints/Symptoms Experiencing/Diagnosis

Duration of symptoms/when did it start:

Contact Number

Email Address 1 (member)

Email Address 2 (optional)

SUPPORTING DOCUMENTS

INSTRUCTION: Please ensure that all relevant supporting documents are prepared before submitting your request. After clicking the Submit button, a confirmation pop-up will appear prompting you to upload the available attachments. If you are unable to upload all documents at that time, you may still upload the remaining supporting documents using the upload link provided in the confirmation email. All additional document submissions and information exchanges will take place within the same email thread. Accepted file formats: PDF, JPG, JPEG, PNG.