Outpatient Plus Online Application

Contact your agent for clarifications or inquries.    
Are you assisted by an agent :       YES       NO

Kindly provide the Agent Code :
 
  FOR APPLICANT * ALL FIELDS ARE REQUIRED
FAMILY NAME: FIRST NAME: MIDDLE INITIAL:
 
BIRTHDATE: SEX: NATIONALITY:
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(YYYY/MM/DD)
 
CIVIL STATUS: HEIGHT: WEIGHT:
 
EMAIL ADDRESS: CONTACT NO(s).: PLACE OF BIRTH:
 
 
 
  CLIENT/PAYOR * ALL FIELDS ARE REQUIRED
FAMILY NAME: FIRST NAME: MIDDLE INITIAL:
 
RELATIONSHIP TO APPLICANT: EMAIL: TIN:
 
SSS NUMBER: SOURCE OF INCOME: OCCUPATION:
 
NAME OF EMPLOYER/BUSINESS: NATURE OF WORK:
 
Before proceeding to payment, please be reminded that you have fifteen (15) days to cancel the agreement after receiving the card and the contract. Please note that the cancellation should be in accordance with the free look clause mentioned in the contract.

If, within twenty-four (24) hours after completing the payment, you haven’t received any notice on how to proceed and get your card, please send an email to retailproducts@medicardphils.com or check your spam folder.

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 maricohermoso@medicardphils.com.
 
  DECLARATIONS AND AGREEMENT

  1. I confirm that all statements and answers contained in this application form are true and complete.
  2. DATA PRIVACY NOTICE.

    MediCard values your privacy and abides by the Principles of Transparency, Legitimate Purpose and Proportionality enshrined in the Philippine Data Privacy Act of 2012.

    Accordingly, MediCard processes, using any medium, any information pertaining to this application and all submitted documents, including relevant medical information, to provide our products and services. The information and documents are also disclosed to the Company’s affiliations (including but not limited to any of its subsidiaries/affiliates in the Asia Pacific Region), its Brokers, Agents, and their employees and staff and to accredited/affiliated third parties or independent/non-affiliated third parties, whether local or foreign, including health care providers.

    Your information and documents are retained by MediCard as long it is necessary to fulfill the purposes in the Privacy Notice/Statement unless a longer retention period is required under the applicable laws or regulations. MediCard will use such information in the application form and all related documents to conduct automated processing, data analytics, profiling, historical research (a) to improve the Company’s internal systems and processes, (b) for actuarial assumptions, (c) in internal and external company reports, and (d) to develop and implement business strategies.
. . .

  By ticking the box, you agree with the declarations and terms above.

I   / to receive promotional information from MediCard and affliated companies within AIA Philippines Group about their products, services, or perks which may be of interest or benefit to me.

I further   / 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.


Dear Valued Client,

We extend our gratitude for entrusting us with your healthcare requirements. In connection with this, we kindly request your careful review of the MediCard Outpatient Plus Healthcare Program Agreement accessible on our website. This document outlines the details of the healthcare package tailored specifically for this product.

Should you require any further information or seek clarifications, please don't hesitate to reach out to the designated point of contact.

Telephone number: 8810-0210
Mobile phone number: 0908 865 5980
Email address: retailproducts@medicardphils.com & prepaidproducts@medicardphils.com

To confirm your acceptance, we kindly ask that you tick the box below.

Once again, we appreciate the confidence you've shown in allowing us to cater to your health needs.

Thank you for entrusting your health to us.

MediCard Philippines, Inc.

  By ticking the box, you accept the terms outlined in the Health Program Agreement available for viewing, including its exclusions and limitations provisions.

  PAYMENT
AMOUNT: Php 6,990.00

PAYMENT CAN BE MADE THRU: