MediCard Philippines, Inc.

URG – FO – 001
Head office: 8th Floor The World Center Bldg., Rev. 02
330 Sen. Gil Puyat Avenue, Salcedo Village, Makati City 1200
Tel. Nos.: (02) 8884-9999 / 8841-8080 • Toll Free: 1800-1888-9001
1 JANUARY 2020
Fax No.: (02) 8810-3855
Text: Key in REG <NAME> and send to 0917 851-2648 (Globe) or
0908 884-1814 (Smart & Sun Subscribers)
E-mail: inquiry@medicardphils.com
Website: www.medicardphils.com

APPLICATION FOR MEMBERSHIP

INSTRUCTIONS:
PLEASE PRINT OR TYPE YOUR ANSWER TO THE QUESTIONS AND CHECK THE APPROPRIATE BOX WHERE APPLICABLE.
USE INK. DO NOT FILL-OUT SHADED BOX, THIS IS FOR EDP USE ONLY.

FAMILY NAME FIRST NAME MI BIRTHDATE PLACE OF BIRTH

YYYY MM DD
SEX CIVIL STATUS HEIGHT WEIGHT NATIONALITY CONTACT No(s). EMAIL ADDRESS
MALE SINGLE WIDOW / WIDOWER FT. IN. LBS.
FEMALE MARRIED SEPARATED
PRESENT ADDRESS: UNIT/BLDG., NUMBER, STREET, SUBDIVISION, BARANGAY CITY PROVINCE TIN NUMBER

PERMANENT ADDRESS: UNIT/BLDG., NUMBER, STREET, SUBDIVISION, BARANGAY CITY PROVINCE SSS NUMBER

TYPE OF PLAN OCCUPATION GROUP/CORPORATE NAME NATURE OF WORK

(I)NDIVIDUAL (G)ROUP
(F)AMILY (C)ORPORATE
PRINCIPAL/PAYOR (FOR APPLICANT UNDER PLAN TYPES F, G, OR C) RELATIONSHIP TO PRINCIPAL/PAYOR
LAST NAME FIRST NAME MI

ROOM PLAN MODE OF PAYMENT SOURCE OF INCOME INSURANCE BENEFICIARY

ANNUAL QUARTERLY EMPLOYED PENSION (NOT MINOR, FOR SME OR CORPORATE ACCOUNTS ONLY)

SEMI-ANNUAL MONTHLY SELF EMPLOYED OTHERS

AGENT: LAST NAME FIRST NAME MI CODE

1. Have you ever been treated for or ever had any known indication of: Yes No DETAILS OF “Yes” ANSWERS, IDENTIFY QUESTION NUMBER,
a. Disorder of eyes, ears, nose, or throat? CIRCLE APPLICABLE ITEMS: (Include diagnosis, results, dates,
b. Dizziness, fainting, convulsions, headache, speech defect, paralysis duration and names and addresses of all attending physicians and
or stroke, mental or nervous disorder? medical facilities)
c. Shortness of breath, persistent hoarseness or cough, blood-spitting
bronchitis, pleurisy, asthma, emphysema, tuberculosis or chronic
respiratory disorder?
d. Chest pain, palpitation, high blood pressure, rheumatic fever, heart
murmur, heart attack, or other disorders of the heart or blood vessels?
e. Jaundice, intestinal bleeding, ulcer, hernia, appendicitis, diverticulitis
colitis, hemorrhoids, recurrent indigestion, or other disorders of the
stomach, intestines, liver or gallbladder?
f. Sugar, albumin, blood or pus in urine, venereal disease, stone or
other disorders of kidney, bladder, prostate or reproductive organs?
g. Diabetes, thyroid or other endocrine disorders?
h. Neuritis, sciatica, rheumatism, arthritis, gout, or disorder of the
muscles or bones, such as spine, back or joints?
i. Deformity, lameness or amputation?
j. Disorder of skin, lymph glands, cysts, tumor, or cancer?
k. Allergies, anemia or other disorders of the blood?
l. Excessive use of alcohol, tobacco or any habit-forming drugs?

2. Are you now under observation or taking treatment?

3. Do you smoke cigarette? If so, how many sticks a day?

4. Other than above, have you:

a. Had any physical disorder or any known indication thereof?
b. Had a medical examination, consultation, illness, injury, surgery?
c. Been a patient in a hospital, clinic, sanitarium, or other medical facility?
d. Had electrocardiogram, x-ray, other diagnostic tests?
e. Been advised to have any diagnostic test, hospitalization, or surgery,
which was not completed?

5. Have you ever had military service deferment, rejection or

discharge because of physical or mental condition?

6. Have you ever applied for or received a pension, payment, or

benefit due to injury, sickness or disability?

7. Do you have a parent, brother, sister who died of or had high

blood pressure, tuberculosis, diabetes, cancer, heart or kidney
disease, or mental illness?
8. FOR FEMALES ONLY:
a. Have you ever had any abnormal menstruation, pregnancy, childbirth
or disorder of the female organs or breast?
b. Are you now pregnant? If yes, how many months?
c. Are you taking contraceptive pills?
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? If Yes, please explain.
This medical questionnaire must be updated to include any condition or disease which occurs after the date of submission of the application and prior to MediCard’s
acceptance. Failure to provide this information to MediCard will constitute a misrepresentation of the presence of a pre-existing condition or disease and may void the
coverage. Receipt of membership fees by MediCard does not constitute acceptance of the application as a MediCard program member. MediCard reserves the right to
reject any applicant and is not obligated to disclose the reason for rejection.

We hereby certify that the foregoing answers are true and complete and to the best of our knowledge. Our health is accurately represented in the above statements. We
understand that MediCard may require us to have a physical examination and we authorize the release of any information from such examination to MediCard for use in
considering our application. We also understand and agree that whenever necessary in the administration of the Service Agreement, MediCard physicians may discuss
with any hospital, health care facility, physician and surgeon, or other health care professionals medical information related in this application. We understand that this
information is collected in connection with the evaluation and processing of any application for coverage or a change of benefits, or to determine eligibility for benefits.

We apply for MediCard program membership and agree that we shall abide by the provisions of the Contract and MediCard regulations. We understand that there is no
coverage unless our application is approved by the MediCard Underwriting Group and that MediCard will not be liable for any medical bills between the time that we sign
this application and the effective date of our coverage if our application is approved. Any money we may have sent will be returned if the application is rejected, except our
processing fee.

Note: In the event the applicant is applying alone or is a minor, the applicant’s name should be entered on the “Signature of Applicant” line, and the applicant’s payor, parent
or guardian or family member should sign where indicated.

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 information with our accredited healthcare providers who may also be responsible in rendering our 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.medicardphilscom/privacy or email privacy@medicardphils.com
for more information

By signing below, we will consider that you agree to give your Consent to us. If in case, applicant/patient/claimant is unable to sign, his/her authorized representative
may warrant that he/she has full authority to sign on behalf of the applicant/patient/claimant.

SIGNATURE OVER PRINTED NAME / RELATIONSHIP TO APPLICANT DATE

WITNESSED BY:

HealthCardPH Inc. 01252021090516

SIGNATURE OF SOLICITING AGENT AGENT’S CODE NUMBER SIGNATURE OF APPLICANT DATE

HealthCardPH Inc.
NAME OF AGENCY SIGNATURE OF APPLICANT’S DATE
PAYOR, PARENT OR GUARDIAN
OR FAMILY MEMBER

MEDICAL ACTION / DATE

(A)PPROVED
(D)ISAPPROVED
D(E)FERRED YYYY MM DD

MEDICAL DEPARTMENT REMARKS