RxER Online Application

FOR APPLICANT * ALL FIELDS ARE REQUIRED
Principals/Sponsors who will enroll any beneficiaries are deemed to have secured the proper consent from the said beneficiaries that they have been designated as such.

FAMILY NAME: FIRST NAME: MI:
 
BIRTHDATE: SEX: NATIONALITY:
(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: MI:
 
RELATIONSHIP TO APPLICANT: EMAIL: TIN:
 
SSS NUMBER: SOURCE OF INCOME: OCCUPATION:
 
NAME OF EMPLOYER/BUSINESS: NATURE OF WORK:
 
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.
 
  PAYMENT
AMOUNT: Php 1,998.00

PAYMENT CAN BE MADE THRU:
 
    (You will receive a virtual card which you may print and present upon availment of benefits)
  • Any 7-Eleven branches (Settle only P1,900 when paying through 7-11)
  • Any ECPay merchant partners
    Pay with a credit or debit card

    Visa   MasterCard   JCB   American Express

           

    Kindly deposit the payment in any of the following banks:
  • Account Name: Medicard Philippines, Inc.
  • RCBC - Account No. 1279940454
  • Banco De Oro - Account No. 001388017802
  • UnionBank - Account No. 101240140960
    (Over-the-Counter, Phonebanking, ATM, Mobile Banking and Online Banking)
  • Account Name: Medicard Philippines, Inc.
  • Banco De Oro - Account No. 001388017802
  • UnionBank - Account No. 101240140960
  • BPI - Account No. 1863176537

Direct payment to the Cashier's office
8th Flr. The World Centre Bldg.
330 Sen. Gil Puyat Avenue, Makati City


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In compliance with the Republic Act of 10173 also known as the Data Privacy Act of 2012, and its Implementing Rules and Regulations, we need your Consent to: (a) allow us to collect, process, or share your information with our accredited healthcare providers who may also be responsible in rendering appropriate medical services to you; and (b) to share utilization data with your Guardian (in case of minor);

To the extent our capacity to render our services to you is affected, the 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 may visit www.medicardphils.com/privacy-notice 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.