NCIA - Online Helpdesk

Member Information

Choose Provider*

Company Code*

Name of Principal*

Patient's Name (Principal/Dependent)*

Birthday*

HMO Card Number

Contact Number*

Email Address 1 (Member)*

Email Address 2 (Optional)

Availment Details

Name of Preferred Hospital/Clinic*

Requesting Doctor*

Date of Availment

Type of Availment

Chief Complaints / Symptoms / Diagnosis

Duration of Symptoms / When Did It Start

Please prepare all required supporting documents before or after submitting your request.
After clicking Submit, a confirmation pop-up will appear prompting you to upload attachments.
If you cannot upload all documents immediately, you may use the link in the confirmation email later.
All succeeding submissions and communications will remain in the same email thread.
Accepted file formats: PDF, JPG, JPEG, PNG.

LOA Request Form