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University of the Philippines
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CU: BAGUIO
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ENHANCED UP HOSPITALIZATION PROGRAMME (UP eHOPE)
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APPLICATION FORM
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Last Name
First Name
Middle Initial
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Position
UnitAge
Civil Status
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Date of Filing
Name of HospitalTotal Amount AppliedPeriod of Hospitalization
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Cause/Reason of Hospitalization:
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Recommended by:
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Unit Head/Administrative OfficerDate
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Employee's Signature(Signature over Printed Name)
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HRDO CLEARANCE
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Appointment Status: Permanent Temporary Casual UP Contractual
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Date of Original Appointment: Active Service
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Number of years in service:
Leave without Pay (LWOP)
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Date of last application: Deducted
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Application Count: 1st 2nd 3rd Others: Not yet deducted
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UP eHOPE Account Balance: as of
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Cleared by:
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Prof. EDNA N. GUECO
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HRDO HeadDate
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EVALUATION / VALIDATION / RECOMMENDATION of the
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HRDO [ ] eHOPE Committee [ ] [N.A.]
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Requirements:
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Medical Certificate from Attending Physician/s
Original OR for Medicines / Laboratory Tests
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Summary Statement of Accounts showing PhilHealth
Surgical Technique (for surgical cases)
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and other health insurance deductions
Discharge Order / Copy of Going Home Instruction,
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Original Official Receipt (OR) of Hospital Bill
if any
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 Other requirements: please specify: _____________________________________________________________________________
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ACTION of the
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HRDO [ ] eHOPE Committee [ ] [N.A.]
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 Approved Disapproved Approved Amount: Php________________________________
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Remarks:
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Prof. EDNA N. GUECO
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HRDO HeadDate
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BUDGET CLEARANCE
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Amount: Php _________________Cleared by: Ms. GLORIA Q. RODRIGUERA Date:_______________________
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 Budget Head
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Recommending Approval:Approved by:
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Dr. SANTOS JOSE O. DACANAY IIIDr. CORAZON L. ABANSI
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Vice Chancellor for AdministrationChancellor
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Date: _______________________________________Date:____________________________________
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