Out Patient Online Application Form

Agent Name

CLIENT/PAYOR

* ALL FIELDS ARE REQUIRED

Family Name:(Required)

First Name:(Required)

Middle Initial:(Required)

Middle Initial

Middle Name is Not Applicable

Not Applicable

Birthdate(Required)

Place of Birth(Required)

Sex(Required)

Nationality(Required)

Email Address(Required)

Mobile Number(Required)

Relation to the applicant(Required)

TIN:

SSS Number:

Source of Income

Occupation(Required)

Name of Employer/Business(Required)

Nature of Work(Required)

Payor Address (Unit/Bldg Number,Street,Subdivision,Barangay)(Required)

City(Required)

Province(Required)

Government ID(Required)

Max. file size: 2 GB.

FOR APPLICANT

* 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)

Place of Birth:(Required)

Sex(Required)

Nationality:(Required)

Civil Status(Required)

Height(Required)

Weight(Required)

Email(Required)

Mobile Number:(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 (Same)

Province (Same)

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 retailproducts@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 mgabat@medicardphils.com and copy furnish maricohermoso@medicardphils.com.

DECLARATIONS AND AGREEMENT

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

DATA PRIVACY NOTICE.

MediCard values your privacy and abides by the Principles of Transparency, Legitimate Purpose and Proportionality enshrined in the Philippine Data Privacy Act of 2012.

Accordingly, MediCard processes, using any medium, any information pertaining to this application and all submitted documents, including relevant medical information, to provide our products and services. The information and documents are also disclosed to the Company’s affiliations (including but not limited to any of its subsidiaries/affiliates in the Asia Pacific Region), its Brokers, Agents, and their employees and staff and to accredited/affiliated third parties or independent/non-affiliated third parties, whether local or foreign, including health care providers.

Your information and documents are retained by MediCard as long it is necessary to fulfill the purposes in the Privacy Notice/Statement unless a longer retention period is required under the applicable laws or regulations. MediCard will use such information in the application form and all related documents to conduct automated processing, data analytics, profiling, historical research (a) to improve the Company’s internal systems and processes, (b) for actuarial assumptions, (c) in internal and external company reports, and (d) to develop and implement business strategies.

DATA PRIVACY CONSENT

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 https://www.medicardphils.com/privacy-statement/ or email privacy@medicardphils.com for more information.

I agree to receive healthcare coverage or Agreement – related information pertaining to the healthcare coverage or Agreement to be issued under this application form, through the mobile phone number and electronic mail address indicated in this application or through any other such contact details that I will advise MediCard in the future.

I agree to be bound by obligations set out in relevant United Nations Security Council Resolutions relating to the prevention and suppression of financing of weapons of mass destruction, including the freezing and unfreezing actions and prohibitions from conducting transactions with designated persons and entities.

I understand that MediCard may prohibit transactions, terminate or consider void any Agreement or coverage, at any time, effective from its issuance or otherwise, in the event I, in the opinion of MediCard, may have or have exposed MediCard to the risk of being or becoming subject to any sanction, prohibition or restriction under the trade or economic sanctions, laws or regulations of the European Union, United Kingdom or United States or America, or any other applicable economic or trade sanction laws or regulations. The same shall apply in the event of our refusal to comply with the Customer Due Diligence requirements which MediCard is mandated to perform under the Anti-Money Laundering Act and relevant regulations.

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.

Telephone number: 8810-0210
Mobile phone number: 0908 865 5980
Email address: retailproducts@medicardphils.com & prepaidproducts@medicardphils.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.

MediCard Philippines, Inc.