DISTRIBUTION CHANNEL INFORMATION

AGENT/BROKER CODE:
Application Form BUSINESS PARTNER MERCHANT CODE:

NOTE:
- PLEASE WRITE LEGIBLY AND ACCOMPLISH ALL FIELDS IN BLOCK LETTERS.
- WRITE N/A FOR FIELDS THAT ARE NOT APPLICABLE.
- ALL FIELDS MUST BE COMPLETED OR ELSE APPLICATION WILL NOT BE PROCESSED.

GET STARTED WITH YOUR HEALTHCARE

I’m a new applicant I’m applying for myself and my family I’m reapplying I’m transferring via Maxilink
I am applying my dependents I am applying for additional dependent(s) on my renewal account

SELECT A PLAN TYPE

PLATINUM PLUS PLATINUM GOLD SILVER
Maximum Benefit Limit (MBL) P 200,000 P 150,000 P 100,000 P 60,000
Room and Board (R&B) Large Private Regular Private Regular Private Semi-Private

DENTAL COVERAGE PHILHEALTH MEMBER

Yes No Yes No

ABOUT THE PLANHOLDER

Principal - An individual who directly entered into an Agreement with Maxicare
Payor - Refers to a non-member or non-enrollee who is the Sponsoring Entity, duly authorized representative and/or legal guardian of a
minor enrollee responsible for the processing, application, submission of proofs of eligibility and fulfilling the financial obligations of the
minor enrollee

LAST NAME FIRST NAME MIDDLE NAME EXTENSION NAME (Jr., Sr., I,II)

BIRTHDATE(MM/DD/YYYY) AGE GENDER CIVIL STATUS NATIONALITY NO. OF CHILDREN

PLACE OF BIRTH

PRESENT ADDRESS BILLING ADDRESS

HOUSE NO. HOUSE NO.
STREET STREET
VILLAGE VILLAGE
BARANGAY BARANGAY
TOWN/MUNICIPALITY TOWN/MUNICIPALITY
PROVINCE PROVINCE
ZIP CODE ZIP CODE
Please check if same as permanent address Please check if same as permanent address

WORK INFORMATION
EMAIL ADDRESS HOME NO. MOBILE NO. OFFICE PHONE NO.

BUSINESS INFORMATION
NAME OF OFFICE/BUSINESS JOB TITLE PHILHEALTH NO.

IF WORKING FOR A COMPANY, IS IT BASED IN THE PHILIPPINES? YES NO

SOURCE/S OF FUNDS SALARY BUSINESS SAVINGS SALE OF ASSET GIFT/INHERITANCE
(CHECK ALL THAT APPLY) INVESTMENT REMITTANCE FROM (COUNTRY) OTHERS:
ABOUT YOUR HEALTH
BLOOD PRESSURE \ HEIGHT(FT. IN.) WEIGHT (LBS)

Have you been diagnosed with any of this condition/disease/disorder?

Neurologic (brain, cord, nerves) Congenital
Psychiatric (mental) Endocrine (pituitary, thyroid, adrenals)
Ophthalmologic (eyes)
Cancer
Otolaryngologic (ears, nose, throat)
Dermatologic (nails, skin, scalp)
Cardiovascular (heart and blood vessels)
Orthopedic (bone)
Pulmonary (lungs)
Hematologic (blood)
Gastrointestinal (esophagus, stomach, intestine, liver, etc.)
Urogenital/ Renal (kidney, prostate, etc.) Surgical
Reproductive/ OB GYN (uterus, fallopian tubes, ovaries, etc.) Autoimmune/ Connective Tissue Disease Infection
Allergy
Are you taking any maintenance medicines?Please specify:

ABOUT THE PLANHOLDER’S DEPENDENTS

If DATE OF BIRTH PLACE CIVIL BLOOD PHILHEALTH DENTAL
FULL NAME OF APPLICANT RELATION AGE GENDER (MM/DD/YYYY) OF BIRTH STATUS HEIGHT WEIGHT PRESSURE MEMBER COVERAGE? OCCUPATION
Applying Y/N Y/N
1

DEPENDENT’S PLAN TYPE PLATINUM PLUS PLATINUM GOLD SILVER

FOR FAMILY GROUP ACCOUNTS: 15 DAYS OLD UP AND 21 YEARS AND 5 MONTHS OLD ARE ACCEPTABLE AGES FOR MINOR DEPENDENTS.
CHILDREN WHO ARE 22 YEARS OLD ABOVE WILL BE CONSIDERED AS INDIVIDUAL APPLICANTS.
Note: You are required to submit at least one (1) clear copy of any valid government ID (if a Filipino citizen), or ACR/Passport (if a foreign national)
- with specimen signature. Maxicare may request for additional document(s) when deemed necessary in compliance with government regulations.

HOW WOULD YOU LIKE TO PAY

Annual Semi-Annual Quarterly Over-The-Counter Bank Credit Card Maxicare Office Cashier

Form Template Control: Enrollment Fulfillment/February 20, 2022/FO-UEF-0.022/Rev.05

MAXICARE ENROLLMENT TERMS AND CONDITIONS
The Terms and Conditions contained herein form the contract between me as a Member arrangements or Administrative Services Only (ASO), profiling or historical
and my dependents and Maxicare Healthcare Corporation (“Maxicare”) as the provider of the statistical analysis, providing advice or information which Maxicare and its
services. I and my dependent/s acknowledge that Maxicare reserves the right to modify the Representatives believe may be of interest to me or the Company, to
Terms and Conditions or their policies for availment from time to time. In executing this effectively administer or manage my account, enhance customer services,
document and in affixing my signature hereto, I confirm that: or to communicate with me for any marketing purposes.
1. By enrolling, I acknowledge and agree to abide by all the terms and conditions I retain the right to be informed, to object, access, complain, and rectify, to request for
contained herein and in the Membership Agreement. filtering of certain information, and to the corresponding damages in case of violation of
2. All my representations, warranties and undertakings shall be deemed to be material my rights within the corresponding limitations as set forth in the pertinent laws.
and have been relied upon by Maxicare. Consequently, I shall be directly and solely 9. I shall declare only accurate, truthful, and up-to-date information to Maxicare in the
responsible for the accuracy of any and all information that I submit during enrollment. course of my application and during the effectivity of this policy, and update within
They shall survive the execution and delivery of these Terms and Conditions, 30 calendar days any change in information I have provided. I further agree to be
notwithstanding the consummation of the transaction contem- plated herein. governed by the terms of this policy and the rules and regulations of the Insurance
3. I and my dependents’ availment of the medical services through the use of Maxicare Commission, the Anti-Money Laundering Council, the Bureau of Internal Revenue,
Letter of Authorization (“LOA”) issued by Maxicare's Call Center, Help Desks, Primary the Securities and Exchange Commission, and other applicable Philippine laws and
Care Centers, Customer Care Representatives, Affiliated Coordi- nators and Partners, regulations, as they may be amended from time to time, and other applicable laws,
Maxicare Kiosk, Member Gateway, or Maxicare electronic systems, signifies that I regulations, or issuances of its regulators.
agree with the terms and conditions contained herein and in the Membership 10. During the effectivity of the contract/policy:
Agreement. a. In case Maxicare is unable to comply with relevant customer due diligence (CDD)
4. I agree and understand that in the course of providing service/s to me and/or my measures, as required under the Anti-Money Laundering Act, as amended and
dependents, Maxicare shall engage the services of, and/or interact with, other third relevant issuances, due to no fault of Maxicare, it may apply the following:
parties, such as, but not limited to its parent company, affiliated companies, i. Measures to restrict the services available or prohibit any further transactions on
subsidiaries, financial advisors, affiliated third parties or indepen- dent/non-affiliated the policy until full and proper CDD measures have been successfully
third parties and service providers, whether local or foreign (collectively referred to as conducted; and
"Representatives"). ii. In case the foregoing is unsuccessful, terminate business relationship. This
measure shall only entitle me/my representative to receive the unused portions
5. I understand that Maxicare shall not be responsible for the payment of charges/
of premium, if any.
expenses resulting from:
b. Be bound by obligations set out in relevant United Nations Security Council
a. Availment of the following hospital or medical services/treatment/proce- dures (diagnostic
Resolutions relating to the prevention and suppression of proliferation financing of
and therapeutic):
weapons of mass destruction, including the freezing and unfreezing actions as well
i. those rendered by non-affiliated physicians/specialists or a reliever physician;
as prohibitions from conducting transactions with designated persons and entities.
ii. those not related to this confinement as determined by the Claims Department of
11. I and my dependents hereby represent that, in order to provide the services
Maxicare;
contemplated in the Agreement, the authorities herein provided shall be valid and
iii. those without prior authorization of Maxicare;
iv. those miscellaneous items outside of your/your dependent’s healthcare benefit plan; existing during the term of the Agreement, including any extensions thereof, and
v. room accommodation beyond the benefit plan limits; or until necessary for the establishment, exercise or defense of any claims arising
vi. co-payment and/or coinsurance defined for the service. from the said Agreement.
b. Failure to file PhilHealth benefit claim to cover all PhilHealth costs incurred during 12. I and my dependent/s hereby warrant that we understand our rights and obligations
confinement; pursuant to the Data Privacy Act and its implementing rules and regulations, as the
c. I or my dependent’s personal preference to prolong confinement beyond the attending same may be amended. Consequently, I and my depen- dents hereby agree to
physician's prescribed duration of hospitalization; hold Maxicare and its Representatives free and harmless from and against any and
d. Amount in excess of my or my dependent’s allowable benefit limit in the professional fee all suits or claims, actions, or proceed- ings, damages, costs, and expenses,
of attending doctor/s with whom my or my dependent has prior agreement; including attorney's fees, which may be filed, charged, or adjudged against
e. Benefit availment found to be not covered and deemed excluded under the Membership Maxicare or any of its directors, stockholders, officers, employees, agents, or
Agreement, including concealment, even if unintentional or unrelated to the current
Representatives in connection with or arising from the use, processing and
availment, of relevant medical information, and those in excess of Benefit Limits set out in
disclosure by Maxicare or its Representatives of the aforementioned information
the agreement, even if condition- ally approved by Maxicare. If at the time of issuance of
pursuant to Maxicare’s reliance on my and my dependents’ consent that Maxicare
the LOA, the amount of my or my dependent’s previous availment is not reflected yet,
Maxicare reserves the right to re-adjudcate the Member’s coverage based on the total and its Represen- tatives have the authority to examine, use, process, store or
remaining balance of the benefit limit; and disclose, as the case may be, said information for the above-mentioned purposes.
f. Other expenses and charges analogous to the foregoing. Maxicare shall collect from me 13. Maxicare shall not be liable for any loss or damage of whatever nature in
the expenses incurred relative to any availment, if upon post verification by Maxicare, any connection with the implementation of transactions covered by this Terms and
of the above-mentioned circumstances shall be found present. My request for LOA may Conditions in the following instances:
likewise be denied outright in the event that the availment is not coverable by Maxicare. a. Disruption, failure or delay which are due to circumstances beyond the control of
1. In lieu of signing the LOA, I or my dependent/s may confirm the availment of the medical Maxicare, fortuitous events such as but not limited to prolonged power outages,
services through electronic confirmation of the transaction via personal identification number breakdown in computers and communica- tion facilities, typhoons, public
(PIN), email, or other electronic confirmation which the facility shall allow. It is my responsibility disturbances and calamities, and other similar or related cases;
to ensure that any changes in my and my dependent/s’ contact information are duly b. Loss or damage I and my dependents’ may suffer due to theft or unauthorized use of
communicated to Maxicare to enable my or my dependent/s to receive the electronic my or my dependents’ MaxicareCard, passwords, personal data, or violation of other
notifications for the transaction accordingly. security measure with or without your participation; and
2. I confirm that the benefits and coverage requiring the services of a physician shall only be c. Inaccurate, incomplete or delayed information you received due to disruption or
performed by an Affiliated Physician or Specialist referred by Maxicare. I and my dependents’ failure of any communication facilities.
are aware that there are agreed standard Professional Fees for specific medical services 14. I hereby warrant that I have been duly authorized by my dependent/s to sign and
between the Physicians and Maxicare. Should I or my dependent/s undertake a private execute any and all documents and make representations for and in his/their behalf
arrangement with the Physician or Specialist for higher Professional Fee/s, I shall be as if the same were personally done by him/them.
personally liable to pay the incremental charges resulting from said balance billing. In no case 15. The Terms and Conditions contained herein are governed by the laws of the
can I demand for reimbursement from Maxicare for the balance billing charged by the
Philippines and all suits to enforce the agreement between me and Maxicare or its
Affiliated Physician or Specialist.
Representatives shall be settled in the proper courts of Makati City.
3. I and my dependent/s have freely, knowingly and voluntarily given my consent for Maxicare
16. Maxicare shall not be liable for any loss, liability, damage or expense arising out of
and its Representatives to:
or in connection with the use of the Online Enrollment System, unless such loss,
a. Obtain, collect, examine, process, and store copies of my and/or my depen- dents’
personal information, including sensitive personal information, privileged information, liability, damage or expense shall be proven to result directly from the gross and
medical records or any other information or material, i.e., picture, voice recording, willful misconduct of Maxicare or its Representatives. In no event will Maxicare be
fingerprints, and etc., relative to my (and/or my dependents’) hospitalization, consultation, liable for special, indirect, punitive or consequential damages. Under no
treatment or any medical advice in connection with the benefit/clai availed under the circumstances will the liability of Maxicare exceed, in the aggregate, the fees
Agreement as may be deemed necessary by Maxicare. Except as otherwise stated actually paid pursuant to the Service Agreement.
hereon, any information obtained relative to the authority herein given shall be strictly 17. Maxicare reserves the right to amend these Terms and Conditions at any time
confidential. The extent of the collection and processing shall be necessary and incidental without the need of prior notice or approval.
to the performance of the services contemplated in the Agreement.
b. Disclose such information to the Company, its representatives, agents and brokers,
Maxicare and its Representatives, including the service providers which will perform the
services contemplated in the Agreement, and relevant government agencies in (Printed Name & Signature) Date
compliance with the Republic Act No. 11223 otherwise known as the “Universal Health Principal Member
Care Act”, for any legitimate business purpose as Maxicare may deem appropriate, *The Terms and Conditions are subject to change. You may access
including but not limited to outsourced proceding of Maxicare transactions, billing of https://maxicare.ph/member-terms for the latest version of the Membership Terms
and Conditions and address any queries related thereto to
co-pay compliance@maxicare.com.ph.
REMINDERS ON PRE-EXISTING CONDITIONS

1. I have read and understood the contents of the MyMaxicare brochure enumerating the exclusions, limitations and other terms and conditions which will
govern my membership with Maxicare.
2. I agree and understand that should my medical condition be diagnosed by a Maxicare affiliated physician as a Pre-Existing Condition, the limitations
on Pre-Existing Conditions as stated in the brochure provided to me will apply.

I have read the MyMaxicare application form, conditions of enrollment and authorization stated above and fully understand and agree to
them.

Signature of Applicant (or legal guardian) Date

Signature Over Printed Name

I hereby authorize my Business Partner to receive a copy of my Official Receipt, billing invoice and other pertinent documents relative to this
application and/or account.
Note: this is only applicable for accounts under agents or brokers.

This portion is to be accomplished by Business Partner

Business Partner Email Address Contact

Form Template Control: Enrollment Fulfillment/February 20, 2022/FO-UEF-0.022/Rev.05