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2025-03-09T06:50:23+08:00
Apply Now
Step
1
of
3
33%
FOR APPLICANT
Coverage Limit Preferred
(Required)
Choose Plan
Standard
VIP
Standard Plan
(Required)
Ward Plan (50K Coverage per illness)
Semi Private Plan (60K Coverage per illness)
Semi Private Plan (100K Coverage per illness)
Small Private Plan (120K Coverage per illness)
VIP Plan
(Required)
Regular Private (200K Coverage per illness)
Regular Private (250K Coverage per illness)
Large Private (300K Coverage per illness)
Suite (500K Coverage per illness)
Family Name:
(Required)
First Name:
(Required)
Middle Initial:
(Required)
Middle Initial
Middle Name is Not Applicable
Not Applicable
Birthdate:
(Required)
MM slash DD slash YYYY
Sex:
(Required)
Female
Male
Nationality:
(Required)
Civil Status:
(Required)
Single
Married
Separated
Widow
Height:
(Required)
Weight (lbs):
(Required)
Email:
(Required)
Mobile Number:
(Required)
Place Of Birth:
(Required)
PRESENT ADDRESS (UNIT/BLDG.,NUMBER,STREET,SUBDIVISION,BARANGAY):
(Required)
City:
(Required)
Province:
(Required)
Permanent Address is Same as Present
Same As Present
PERMANENT ADDRESS (UNIT/BLDG.,NUMBER,STREET,SUBDIVISION,BARANGAY):
(Required)
City (Permanent Address)
(Required)
Province (Permanent Address)
(Required)
PERMANENT ADDRESS (UNIT/BLDG.,NUMBER,STREET,SUBDIVISION,BARANGAY)
City
Province
SSS:
TIN:
Occupation:
(Required)
Group/Corporate Name:
(Required)
Nature of Work:
(Required)
Type of Plan:
(Required)
Individual
Family
Government ID (Applicant)
(Required)
Max. file size: 2 GB.
*Note: Only jpg,png,pdf formats are allowed.
Communications will be sent through your given email, mobile number, or address. Should you need to update any information or contact details, please get in touch with us via email to: mgabat@medicardphils.com and copy furnish: kfvillanueva@medicardphils.com.
No. of Dependents
(Required)
0
1
2
3
4
PERSONAL INFORMATION (DEPENDENT 1)
Family Name (1):
(Required)
First Name (1):
(Required)
Middle Initial (1)
Type 'NONE' if not applicable
Birthdate (1)
(Required)
MM slash DD slash YYYY
Sex (1)
(Required)
Male
Female
Nationality (1)
(Required)
Civil Status (1)
(Required)
Single
Married
Separated
Widow
Email (1)
(Required)
Mobile Number (1)
(Required)
Relationship to Principal/Payor (1)
(Required)
Mother
Father
Sister
Brother
Son
Daughter
Wife
Husband
Government ID (1)
(Required)
Max. file size: 2 GB.
Note: A birth certificate is required for dependents aged 18 years and below.
PERSONAL INFORMATION (DEPENDENT 2)
Family Name (2):
(Required)
First Name (2):
(Required)
Middle Initial (2)
Type 'NONE' if not applicable
Birthdate (2)
(Required)
MM slash DD slash YYYY
Sex (2)
(Required)
Male
Female
Nationality (2)
(Required)
Civil Status (2)
(Required)
Single
Married
Separated
Widow
Email (2)
(Required)
Mobile Number (2)
(Required)
Relationship to Principal/Payor (2)
(Required)
Mother
Father
Sister
Brother
Son
Daughter
Wife
Husband
Government ID (2)
(Required)
Max. file size: 2 GB.
Note: A birth certificate is required for dependents aged 18 years and below.
PERSONAL INFORMATION (DEPENDENT 3)
Family Name (3):
(Required)
First Name (3):
(Required)
Middle Initial (3)
Type 'NONE' if not applicable
Birthdate (3)
(Required)
MM slash DD slash YYYY
Sex (3)
(Required)
Male
Female
Nationality (3)
(Required)
Civil Status (3)
(Required)
Single
Married
Separated
Widow
Email (3)
(Required)
Mobile Number (3)
(Required)
Relationship to Principal/Payor (3)
(Required)
Mother
Father
Sister
Brother
Son
Daughter
Wife
Husband
Government ID (3)
(Required)
Max. file size: 2 GB.
Note: A birth certificate is required for dependents aged 18 years and below.
PERSONAL INFORMATION (DEPENDENT 4)
Family Name (4):
(Required)
First Name (4):
(Required)
Middle Initial (4)
Type 'NONE' if not applicable
Birthdate (4)
(Required)
MM slash DD slash YYYY
Sex (4)
(Required)
Male
Female
Nationality (4)
(Required)
Civil Status (4)
(Required)
Single
Married
Separated
Widow
Email (4)
(Required)
Mobile Number (4)
(Required)
Relationship to Principal/Payor (4)
(Required)
Mother
Father
Sister
Brother
Son
Daughter
Wife
Husband
Government ID (4)
(Required)
Max. file size: 2 GB.
Note: A birth certificate is required for dependents aged 18 years and below.
MEDICAL INFORMATION (PRINCIPAL)
1. Have you ever been treated for or ever had any known indication of:
1.1. Disorder of eyes, ears, nose, or throat?
(Required)
Yes
No
1.2. Dizziness, fainting, convulsions, headache, speech defect, paralysis or stroke, mental or nervous disorder?
(Required)
Yes
No
1.3. Shortness of breath, persistent hoarseness or cough, blood-spitting bronchitis, pleurisy, asthma, emphysema, tuberculosis or chronic respiratory disorder?
(Required)
Yes
No
1.4. Chest pain, palpitation, high blood pressure, rheumatic fever, heart murmur, heart attack or any other disorders of the heart or blood vessels?
(Required)
Yes
No
1.5. Jaundice, intestinal bleeding, ulcer, hernia, appendicitis, diverticulitis colitis, hemorrhoids, recurrent indigestion, or other disorders of the stomach, intestines, liver or gallbladder?
(Required)
Yes
No
1.6. Sugar, albumin, blood or pus in urine, venereal disease, stone or other disorders of kidney, bladder, prostate or reproductive organs?
(Required)
Yes
No
1.7. Diabetes thyroid or other endocrine disorders?
(Required)
Yes
No
1.8. Neuritis, sciatica, rheumatism, arthritis, gout, or disorder of the muscles or bones, such as spine, back or joints?
(Required)
Yes
No
1.9. Deformity, lameness or amputation?
(Required)
Yes
No
1.10. Disorder of skin, lymph glands, cysts, tumor or cancer?
(Required)
Yes
No
1.11. Allergies, anemia or other disorders of the blood?
(Required)
Yes
No
1.12. Excessive use of alcohol, tobacco or any habit-forming drugs?
(Required)
Yes
No
2. Are you now under observation or taking treatment?
(Required)
Yes
No
3. Do you smoke cigarette?
(Required)
Yes
No
4. Other than above, have you:
4.1. Had any physical disorder or any known indication thereof?
(Required)
Yes
No
4.2. Had a medical examination, consultation, illness, injury, surgery?
(Required)
Yes
No
4.3. Been a patient in a hospital, clinic, sanitarium, or other medical facility?
(Required)
Yes
No
4.4. Had electrocardiogram, x-ray, other diagnostic tests?
(Required)
Yes
No
4.5. Been advised to have a diagnostic test, hospitalization, or surgery which was not completed?
(Required)
Yes
No
5. Have you ever had military service deferment, rejection or discharge because of physical or mental condition?
(Required)
Yes
No
6. Have you ever applied for or received a pension, payment, or benefit due to injury, sickness or disability?
(Required)
Yes
No
7. Have you a parent, brother, sister who died of or had high blood pressure, tubercolosis, diabetes, cancer, heart or kidney disease, or mental illness?
(Required)
Yes
No
8. FOR FEMALES ONLY:
a. Have you ever had any abnormal menstruation, pregnancy, childbirth or disorder of the female organs or breast?
Yes
No
b. Are you now pregnant?
Yes
No
c. Are you taking contraceptives pills?
Yes
No
9. Have you ever been rejected or terminated for medical insurance including MediCard program, or have been offered insurance at a higher (rated-up) premium?
Yes
No
In compliance with Republic Act 10173 also known as the Data Privacy Act of 2012, we need your Consent to allow us to collect and process your information. We will only disclose and share your personal and health information with your Company and its agents or brokers (if applicable), your own agent or broker (if any), with MEDICard's officers, directors, employees, agents, consultants, contractors, representatives, affiliated companies within AIA Group, and recognized service providers which include MEDICard's accredited hospitals/clinics, physicians, diagnostic service centers, and other allied health professionals with our accredited healthcare providers who may also be responsible in rendering appropriate medical services to you.
Withholding or withdrawal of such Consent shall relieve us from our obligation to deliver the appropriate services to you.
You are afforded with certain rights and protection in accordance with the said Act and you may visit www.medicardphils.com/privacy or email privacy@medicardphils.com for more information.
Consent
(Required)
By ticking the box, we will consider that you agree to give your Consent to us.
(Required)
Consent
(Required)
I have read and fully understood the terms of the Health Program Agreement
(Required)
Receive Promotional
(Required)
I Agree
I Disagree
to receive promotional information from MEDICard and affiliated companies within AIA Philippines Group about their products, services, or perks which may be of interest or benefit to me.
Use my information for profiling to develop, enhance and offer me.
(Required)
I Agree
I Disagree
for the Company to use my information for profiling to develop, enhance and offer me/us financial and HMO services and products that the Company considers as suitable for my/our HMO/insurance and other financial needs.
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