MediCard Philippines

MediCard VIP Online Membership

Welcome to the MediCard Online Membership Application, kindly select type of application below.

New applicant Renewal

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

FAMILY NAME:	FIRST NAME:	MI:

		NOT APPLICABLE
BIRTHDATE:	SEX:	NATIONALITY:
AGE:

PLACE OF BIRTH:	MOBILE NUMBER:


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


CITY:	PROVINCE:


MODE OF PAYMENT:	SOURCE OF INCOME:


ROOM PLAN:	ACCOUNT OFFICER:	INSURANCE BENEFICIARY: (Not minor, for SME or Corporate Accounts Only)

FOR APPLICANT

FAMILY NAME:	FIRST NAME:	MI:

		NOT APPLICABLE
BIRTHDAY:	SEX:	NATIONALITY:

AGE:
CIVIL STATUS:	HEIGHT:	WEIGHT (lbs):


EMAIL ADDRESS:	MOBILE NUMBER:	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.

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.

	1. Have you ever been treated for or ever had any known indication of:
Yes No	1.1. Disorder of eyes, ears, nose, or throat?
Yes No	1.2. Dizziness, fainting, convulsions, headache, speech defect, paralysis or stroke, mental or nervous disorder?
Yes No	1.3. Shortness of breath, persistent hoarseness or cough, blood-spitting bronchitis, pleurisy, asthma, emphysema, tuberculosis or chronic respiratory disorder?
Yes No	1.4. Chest pain, palpitation, high blood pressure, rheumatic fever, heart murmur, heart attack or any other disorders of the heart or blood vessels?
Yes No	1.5. Jaundice, intestinal bleeding, ulcer, hernia, appendicitis, diverticulitis colitis, hemorrhoids, recurrent indigestion, or other disorders of the stomach, intestines, liver or gallbladder?
Yes No	1.6. Sugar, albumin, blood or pus in urine, venereal disease, stone or other disorders of kidney, bladder, prostate or reproductive organs?
Yes No	1.7. Diabetes thyroid or other endocrine disorders?
Yes No	1.8. Neuritis, sciatica, rheumatism, arthritis, gout, or disorder of the muscles or bones, such as spine, back or joints?
Yes No	1.9. Deformity, lameness or amputation?
Yes No	1.10. Disorder of skin, lymph glands, cysts, tumor or cancer?
Yes No	1.11. Allergies, anemia or other disorders of the blood?
Yes No	1.12. Excessive use of alcohol, tobacco or any habit-forming drugs?
Yes No	2. Are you now under observation or taking treatment?
Yes No	3. Do you smoke cigarette?
	4. Other than above, have you:
Yes No	4.1. Had any physical disorder or any known indication thereof?
Yes No	4.2. Had a medical examination, consultation, illness, injury, surgery?
Yes No	4.3. Been a patient in a hospital, clinic, sanitarium, or other medical facility?
Yes No	4.4. Had electrocardiogram, x-ray, other diagnostic tests?
Yes No	4.5. Been advised to have a diagnostic test, hospitalization, or surgery which was not completed?
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?
Yes No	b. Are you now pregnant?
Yes No	c. Are you taking contraceptives pills?
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?
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 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 Health Program Agreement
	I agree / disagree to receive promotional information from MEDICard and affiliated companies within AIA Philippines Group about their products, services, or perks which may be of interest or benefit to me. I further agree / 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.

FOR APPLICANT

FAMILY NAME:	FIRST NAME:	MI:

		NOT APPLICABLE
BIRTHDAY:	SEX:	NATIONALITY:

AGE:
CIVIL STATUS:	HEIGHT:	WEIGHT (lbs):


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	1.1. Disorder of eyes, ears, nose, or throat?
Yes No	1.2. Dizziness, fainting, convulsions, headache, speech defect, paralysis or stroke, mental or nervous disorder?
Yes No	1.3. Shortness of breath, persistent hoarseness or cough, blood-spitting bronchitis, pleurisy, asthma, emphysema, tuberculosis or chronic respiratory disorder?
Yes No	1.4. Chest pain, palpitation, high blood pressure, rheumatic fever, heart murmur, heart attack or any other disorders of the heart or blood vessels?
Yes No	1.5. Jaundice, intestinal bleeding, ulcer, hernia, appendicitis, diverticulitis colitis, hemorrhoids, recurrent indigestion, or other disorders of the stomach, intestines, liver or gallbladder?
Yes No	1.6. Sugar, albumin, blood or pus in urine, venereal disease, stone or other disorders of kidney, bladder, prostate or reproductive organs?
Yes No	1.7. Diabetes thyroid or other endocrine disorders?
Yes No	1.8. Neuritis, sciatica, rheumatism, arthritis, gout, or disorder of the muscles or bones, such as spine, back or joints?
Yes No	1.9. Deformity, lameness or amputation?
Yes No	1.10. Disorder of skin, lymph glands, cysts, tumor or cancer?
Yes No	1.11. Allergies, anemia or other disorders of the blood?
Yes No	1.12. Excessive use of alcohol, tobacco or any habit-forming drugs?
Yes No	2. Are you now under observation or taking treatment?
Yes No	3. Do you smoke cigarette?
	4. Other than above, have you:
Yes No	4.1. Had any physical disorder or any known indication thereof?
Yes No	4.2. Had a medical examination, consultation, illness, injury, surgery?
Yes No	4.3. Been a patient in a hospital, clinic, sanitarium, or other medical facility?
Yes No	4.4. Had electrocardiogram, x-ray, other diagnostic tests?
Yes No	4.5. Been advised to have a diagnostic test, hospitalization, or surgery which was not completed?
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, tuberculosis, 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?
Yes No	b. Are you now pregnant?
Yes No	c. Are you taking contraceptives pills?
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?
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 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 agree / disagree to receive promotional information from MEDICard and affiliated companies within AIA Philippines Group about their products, services, or perks which may be of interest or benefit to me. I further agree / 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.