MediCard Philippines

Yes No

a. Disorder of eyes, ears, nose, or throat?

Yes No

c. Shortness of breath, persistent hoarseness or cough, blood-spitting bronchitis, pleurisy, asthma, emphysema, tuberculosis or chronic respiratory disorder?

Yes No

e. Jaundice, intestinal bleeding, ulcer, hernia, appendicitis, diverticulitis colitis, hemorrhoids, recurrent indigestion, or other disorders of the stomach, intestines, liver or gallbladder?

Yes No

g. Diabetes thyroid or other endocrine disorders?

Yes No

i. Deformity, lameness or amputation?

Yes No

k. Allergies, anemia or other disorders of the blood?

Yes No

2. Are you now under observation or taking treatment?

4. Other than above, have you:

Yes No

b. Had a medical examination, consultation, illness, injury, surgery?

Yes No

d. Had electrocardiogram, x-ray, other diagnostic tests?

Yes No

5. Have you ever had military service deferment, rejection or discharge because of physical or mental condition?

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?

Yes No

a. Have you ever had any abnormal menstruation, pregnancy, childbirth or disorder of the female organs or breast?

Yes No

c. Are you taking contraceptives pills?

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 health care 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.medicardphils.com/privacy or email privacy@medicardphils.com for more information.

By ticking the box, we will consider that you agree to give your Consent to us.
I have read and fully understood the terms of the Memorandum of Agreement

FOR APPLICANT

FAMILY NAME:	FIRST NAME:	MI:

		NOT APPLICABLE
BIRTHDAY:	SEX:	NATIONALITY:

AGE:
CIVIL STATUS:	HEIGHT:	WEIGHT:


EMAIL ADDRESS:	CONTACT NO(s).:	PLACE OF BIRTH:


PRESENT ADDRESS (UNIT/BLDG.,NUMBER,STREET,SUBDIVISION,BARANGAY):

CITY:	PROVINCE:


PERMANENT ADDRESS (UNIT/BLDG.,NUMBER,STREET,SUBDIVISION,BARANGAY):

CITY:	PROVINCE:
		SAME AS PRESENT

SSS:	TIN:	OCCUPATION:


Group/Corporate Name:	NATURE OF WORK:	TYPE OF PLAN


RELATIONSHIP TO PRINCIPAL/PAYOR:	GOVERNMENT ID
		*Note: Only jpg,png,pdf formats are allowed to max size of 5MB.

PRINCIPAL/PAYOR (For applicant under Plan Types F, G or C)

FAMILY NAME:	FIRST NAME:	MI:

		NOT APPLICABLE

MODE OF PAYMENT:	SOURCE OF INCOME:	INSURANCE BENEFICIARY: (Not minor, for SME or Corporate Accounts Only)


ROOM PLAN:	ACCOUNT OFFICER:


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.

FOR APPLICANT

FAMILY NAME:	FIRST NAME:	MI:

		NOT APPLICABLE
BIRTHDAY:	SEX:	NATIONALITY:

AGE:
CIVIL STATUS:	HEIGHT:	WEIGHT:


EMAIL ADDRESS:	CONTACT NO(s).:	PLACE OF BIRTH:


PRESENT ADDRESS (UNIT/BLDG.,NUMBER,STREET,SUBDIVISION,BARANGAY):

CITY:	PROVINCE:


PERMANENT ADDRESS (UNIT/BLDG.,NUMBER,STREET,SUBDIVISION,BARANGAY):

CITY:	PROVINCE:
		SAME AS PRESENT

SSS:	TIN:	OCCUPATION:


Group/Corporate Name:	NATURE OF WORK:	RELATIONSHIP TO PRINCIPAL:


GOVERNMENT ID:
	*Note: Only jpg,png,gif,pdf formats are allowed to max size of 5MB.

	1. Have you ever been treated for or ever had any known indication of:
Yes No	a. Disorder of eyes, ears, nose, or throat? If Yes give details:
Yes No	b. Dizziness, fainting, convulsions, headache, speech defect, paralysis or stroke, mental or nervous disorder? If Yes give details:
Yes No	c. Shortness of breath, persistent hoarseness or cough, blood-spitting bronchitis, pleurisy, asthma, emphysema, tuberculosis or chronic respiratory disorder? If Yes give details:
Yes No	d. Chest pain, palpitation, high blood pressure, rheumatic fever, heart murmur, heart attack or any other disorders of the heart or blood vessels? If Yes give details:
Yes No	e. Jaundice, intestinal bleeding, ulcer, hernia, appendicitis, diverticulitis colitis, hemorrhoids, recurrent indigestion, or other disorders of the stomach, intestines, liver or gallbladder? If Yes give details:
Yes No	f. Sugar, albumin, blood or pus in urine, venereal disease, stone or other disorders of kidney, bladder, prostate or reproductive organs? If Yes give details:
Yes No	g. Diabetes thyroid or other endocrine disorders? If Yes give details:
Yes No	h. Neuritis, sciatica, rheumatism, arthritis, gout, or disorder of the muscles or bones, such as spine, back or joints? If Yes give details:
Yes No	i. Deformity, lameness or amputation? If Yes give details:
Yes No	j. Disorder of skin, lymph glands, cysts, tumor or cancer? If Yes give details:
Yes No	k. Allergies, anemia or other disorders of the blood? If Yes give details:
Yes No	l. Excessive use of alcohol, tobacco or any habit-forming drugs? If Yes give details:
Yes No	2. Are you now under observation or taking treatment?
Yes No	3. Do you smoke cigarette? If so, how many sticks a day?
	4. Other than above, have you:
Yes No	a. Had any physical disorder or any known indication thereof? If Yes give details:
Yes No	b. Had a medical examination, consultation, illness, injury, surgery? If Yes give details:
Yes No	c. Been a patient in a hospital, clinic, sanitarium, or other medical facility? If Yes give details:
Yes No	d. Had electrocardiogram, x-ray, other diagnostic tests? If Yes give details:
Yes No	e. Been advised to have a diagnostic test, hospitalization, or surgery which was not completed? If Yes give details:
Yes No	5. Have you ever had military service deferment, rejection or discharge because of physical or mental condition?
Yes No	6. Have you ever applied for or received a pension, payment, or benefit due to injury, sickness or disability?
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?
	8. FOR FEMALES ONLY:
Yes No	a. Have you ever had any abnormal menstruation, pregnancy, childbirth or disorder of the female organs or breast? If Yes give details:
Yes No	b. Are you now pregnant? If Yes, how many months?
Yes No	c. Are you taking contraceptives pills? If Yes give details:
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? If Yes give details:
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 health care 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.medicardphils.com/privacy or email privacy@medicardphils.com for more information. By ticking the box, we will consider that you agree to give your Consent to us. I have read and fully understood the terms of the Memorandum of Agreement

MediCard Individual/Family Online Membership