FTCC Solutions Inc.

Beneficiary Info

Delivery Option

Submit

GAMOT Request Form

Please provide accurate beneficiary information for faster approval. Ensure all contact details are correct for smooth communication.

All fields marked with * are required. Have your PhilHealth card and GAMOT prescription ready.

PhilHealth Identification Number (PIN) *

0/12

Found on your PhilHealth ID card (12 digits only, no dashes)

Full Name *

Last Name

First Name

Middle Name (Optional)

Suffix (Optional)

Birth Date *

Must match your PhilHealth records

Unique Prescription Security Code (USPC) *

Find the USPC and QR code on your PhilHealth GAMOT prescription from your YAKAP facility doctor.

Signature *

Draw your signature below

Accepted formats: JPG, PNG (Max 2MB)

Pick-Up

Collect your medication from our facility at your convenience

Delivery

Have your medication delivered to your address

I am the beneficiary and will pick up the medication myself

Pick-Up By

Relationship

Preferred Pick-Up Date *

Mobile Number *

We'll send SMS updates about your medication

Email Address *

Confirmation and updates will be sent here

By submitting, you confirm all information is accurate and complete