MediCard VIP Online Membership

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

PERSONAL INFORMATION (PRINCIPAL)
PRINCIPAL/PAYOR (For applicant under Plan Types F, G or C)
 
FAMILY NAME: FIRST NAME: MI:
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:
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:  
 
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.
 
MEDICAL INFORMATION (PRINCIPAL)
1. Have you ever been treated for or ever had any known indication of:
1.1. Disorder of eyes, ears, nose, or throat?
1.2. Dizziness, fainting, convulsions, headache, speech defect, paralysis or stroke, mental or nervous disorder?
1.3. Shortness of breath, persistent hoarseness or cough, blood-spitting bronchitis, pleurisy, asthma, emphysema, tuberculosis or chronic respiratory disorder?
1.4. Chest pain, palpitation, high blood pressure, rheumatic fever, heart murmur, heart attack or any other disorders of the heart or blood vessels?
1.5. Jaundice, intestinal bleeding, ulcer, hernia, appendicitis, diverticulitis colitis, hemorrhoids, recurrent indigestion, or other disorders of the stomach, intestines, liver or gallbladder?
1.6. Sugar, albumin, blood or pus in urine, venereal disease, stone or other disorders of kidney, bladder, prostate or reproductive organs?
1.7. Diabetes thyroid or other endocrine disorders?
1.8. Neuritis, sciatica, rheumatism, arthritis, gout, or disorder of the muscles or bones, such as spine, back or joints?
1.9. Deformity, lameness or amputation?
1.10. Disorder of skin, lymph glands, cysts, tumor or cancer?
1.11. Allergies, anemia or other disorders of the blood?
1.12. Excessive use of alcohol, tobacco or any habit-forming drugs?
2. Are you now under observation or taking treatment?
3. Do you smoke cigarette?
4. Other than above, have you:
4.1. Had any physical disorder or any known indication thereof?
4.2. Had a medical examination, consultation, illness, injury, surgery?
4.3. Been a patient in a hospital, clinic, sanitarium, or other medical facility?
4.4. Had electrocardiogram, x-ray, other diagnostic tests?
4.5. Been advised to have a 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. 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:
a. Have you ever had any abnormal menstruation, pregnancy, childbirth or disorder of the female organs or breast?
b. Are you now pregnant?
c. Are you taking contraceptives 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?
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.


 
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.
PERSONAL INFORMATION (DEPENDENT)
FOR APPLICANT
 
FAMILY NAME: FIRST NAME: MI:
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:  
 
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.
 
MEDICAL INFORMATION (DEPENDENT)
1. Have you ever been treated for or ever had any known indication of:
1.1. Disorder of eyes, ears, nose, or throat?
1.2. Dizziness, fainting, convulsions, headache, speech defect, paralysis or stroke, mental or nervous disorder?
1.3. Shortness of breath, persistent hoarseness or cough, blood-spitting bronchitis, pleurisy, asthma, emphysema, tuberculosis or chronic respiratory disorder?
1.4. Chest pain, palpitation, high blood pressure, rheumatic fever, heart murmur, heart attack or any other disorders of the heart or blood vessels?
1.5. Jaundice, intestinal bleeding, ulcer, hernia, appendicitis, diverticulitis colitis, hemorrhoids, recurrent indigestion, or other disorders of the stomach, intestines, liver or gallbladder?
1.6. Sugar, albumin, blood or pus in urine, venereal disease, stone or other disorders of kidney, bladder, prostate or reproductive organs?
1.7. Diabetes thyroid or other endocrine disorders?
1.8. Neuritis, sciatica, rheumatism, arthritis, gout, or disorder of the muscles or bones, such as spine, back or joints?
1.9. Deformity, lameness or amputation?
1.10. Disorder of skin, lymph glands, cysts, tumor or cancer?
1.11. Allergies, anemia or other disorders of the blood?
1.12. Excessive use of alcohol, tobacco or any habit-forming drugs?
2. Are you now under observation or taking treatment?
3. Do you smoke cigarette?
4. Other than above, have you:
4.1. Had any physical disorder or any known indication thereof?
4.2. Had a medical examination, consultation, illness, injury, surgery?
4.3. Been a patient in a hospital, clinic, sanitarium, or other medical facility?
4.4. Had electrocardiogram, x-ray, other diagnostic tests?
4.5. Been advised to have a 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. 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:
a. Have you ever had any abnormal menstruation, pregnancy, childbirth or disorder of the female organs or breast?
b. Are you now pregnant?
c. Are you taking contraceptives 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?
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.

 
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.