MediCard H.E.R.O. (Health Emergency Response On-demand) Application Form

Contact Facebook Name:(Required)

APPLICANT/INSURED

* ALL FIELDS ARE REQUIRED

Family Name:(Required)

First Name:(Required)

Middle Initial:(Required)

Middle Initial(none):

Middle Name is Not Applicable

Not Applicable

Birthdate(Required)

MM slash DD slash YYYY

Sex(Required)

Nationality(Required)

Civil Status(Required)

Email Address(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) (SAME)

City (Same)

Province (Same)

ID Type(Required)

ID Upload(Required)

Max. file size: 2 GB.

ID NUMBER(Required)

Source of Income

Occupation(Required)

Name of Employer/Business(Required)

Nature of Work(Required)

CLIENT/PAYOR/BUYER

* ALL FIELDS ARE REQUIRED

SAME AS APPLICANT/INSURED INFO

Family Name(Required)

First Name(Required)

Middle Initial(Required)

Middle Initial(none)

Middle Name is Not Applicable 2

Not Applicable

Birthdate:(Required)

MM slash DD slash YYYY

Sex:(Required)

Nationality:(Required)

Civil Status:(Required)

Email Address:(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 2

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)(SAME)

City (Same)

Province (Same)

ID Type(Required)

ID Upload(Required)

Max. file size: 2 GB.

ID NUMBER(Required)

Source of Income:

Occupation:(Required)

Name of Employer/Business:(Required)

Nature of Work:(Required)

Relationship to Applicant(Required)

BENEFICIARY

Family Name :(Required)

First Name :(Required)

Middle Initial :(Required)

Middle Initial(none) :

Middle Name is Not Applicable 3

Not Applicable

Relationship to Applicant:(Required)

Before proceeding to payment, please be reminded that you have fifteen (15) days to cancel the agreement after receiving the card and the contract. Please note that the cancellation should be in accordance with the free look clause mentioned in the contract.

If, within twenty-four (24) hours after completing the payment, you haven’t received any notice on how to proceed and get your card, please send an email to ctpanti@medicardphils.com or check your spam folder.

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 ctpanti@medicardphils.com.

DECLARATIONS AND AGREEMENT

I confirm that all statements and answers contained in this application form are true and complete.

DATA PRIVACY NOTICE.

At CeeCares, we value your privacy. We uphold the Principles of Transparency, Legitimate Purpose, and Proportionality as mandated by the Philippine Data Privacy Act of 2012.

In line with this, CeeCares collects and forwards all submitted application forms and supporting documents—including relevant medical information—to MediCard for processing. MediCard, as the health maintenance organization (HMO) provider, will process the information using any appropriate medium in order to deliver its products and services.

This information may be disclosed by MediCard to its affiliated entities (including subsidiaries and affiliates in the Asia Pacific Region) their employees and staff, as well as to accredited/affiliated third parties or independent/non-affiliated third parties, whether local or foreign, including health care providers.

All information and documents will be retained by MediCard only for as long as necessary to fulfill the purposes stated in its Privacy Notice, unless a longer retention period is required by applicable laws or regulations. MediCard may use the submitted data for automated processing, data analytics, profiling, or historical research in order to (a) improve internal systems and processes, (b) support actuarial assumptions, (c) generate internal and external reports, and (d) develop and implement business strategies.

DATA PRIVACY CONSENT.

In compliance with Republic Act No. 10173, also known as the Data Privacy Act of 2012, CeeCares OPC seeks your consent to collect and forward your personal and health information to MediCard Philippines for processing. This information is essential in facilitating your healthcare coverage application and for the provision of MediCard’s services.

Your personal and health information may be shared by MediCard with the following, as necessary to fulfill its obligations: Your Company and its agents or brokers (if applicable) Your personal agent or broker (if any) MediCard’s officers, directors, employees, agents, consultants, contractors, and authorized representatives, Affiliated companies within the AIA Group, Recognized service providers, including MediCard-accredited hospitals, clinics, physicians, diagnostic centers, and other healthcare professionals responsible for delivering medical services.

Consent(Required)

By ticking the box, you agree with the declarations and terms above.(Required)

Receive Promotional Information(Required)

I agree

I disagree

to receive promotional information from MediCard and affliated companies within AIA Philippines Group about their products, services, or perks which may be of interest or benefit to me.

company to use my information for profiling(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.

Dear Valued Client,

We extend our gratitude for entrusting us with your healthcare requirements. In connection with this, we kindly request your careful review of the MediCard Outpatient Plus Healthcare Program Agreement accessible on our website. This document outlines the details of the healthcare package tailored specifically for this product.

Should you require any further information or seek clarifications, please don't hesitate to reach out to the designated point of contact.

Mobile phone number: +63928 416 0932 / +63928 416 5964
Email address: sales1.medicardph@gmail.com & sales2.medicardph@gmail.com

To confirm your acceptance, we kindly ask that you tick the box below.

Once again, we appreciate the confidence you've shown in allowing us to cater to your health needs.

Thank you for entrusting your health to us.

Consent(Required)

By ticking the box, you accept the terms outlined in the Health Program Agreement available for viewing, including its exclusions and limitations provisions.(Required)