MediCard Philippines

I confirm that all statements and answers contained in this application form are true and complete.
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.

DATA PRIVACY CONSENT
I agree for MediCard to use the information I provided in this application and all related documents in the design and communication of MediCard’s marketing campaigns and offers in order to improve the quality of service MediCard provides, and to receive such marketing campaigns. I agree to share the information with affiliates and third parties for marketing campaigns.

I agree for MediCard to use such information for profiling to develop, enhance and offer products or service which MediCard believes may be of interest to me.

I may, at anytime, withdraw my consent by calling MediCard’s contact center, or by emailing the request to privacy@medicardphils.com. Upon receipt of such withdrawal of consent, MediCard will no longer approach me for promotions or products that may be suited to my medical and financial needs.

For more information about MediCard’s Privacy Statement, kindly visit our website at https://www.medicardphils.com/privacy-notice. You may also email our Data Protection Officer at privacy@medicardphils.com for any privacy related request, inquiry, concerns or clarifications.
I agree to receive healthcare coverage or Agreement – related information pertaining to the healthcare coverage or Agreement to be issued under this application form, through the mobile phone number and electronic mail address indicated in this application or through any other such contact details that I will advise MediCard in the future.
To the extent that the capacity of MediCard to provide its services is affected, I acknowledge and am aware that if I withhold, revoke or cancel the consent given in this form, I cannot compel MediCard or any of its affiliates, networks, employees and representatives to deliver any form of service or benefit to me, thereby waiving my entitlement to such services and benefits.
I agree to be bound by obligations set out in relevant United Nations Security Council Resolutions relating to the prevention and suppression of financing of weapons of mass destruction, including the freezing and unfreezing actions and prohibitions from conducting transactions with designated persons and entities.
I understand that MediCard may prohibit transactions, terminate or consider void any Agreement or coverage, at any time, effective from its issuance or otherwise, in the event I, in the opinion of MediCard, may have or have exposed MediCard to the risk of being or becoming subject to any sanction, prohibition or restriction under the trade or economic sanctions, laws or regulations of the European Union, United Kingdom or United States or America, or any other applicable economic or trade sanction laws or regulations. The same shall apply in the event of our refusal to comply with the Customer Due Diligence requirements which MediCard is mandated to perform under the Anti-Money Laundering Act and relevant regulations

Dear Sir/Madam,

We extend our gratitude for entrusting us with your healthcare requirements. In connection with this, we kindly request your careful review of the MediCard RxER 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 stated above..

FAMILY NAME:	FIRST NAME:	MIDDLE INITIAL:

		NOT APPLICABLE

RELATIONSHIP TO APPLICANT:	EMAIL:	TIN:


SSS NUMBER:	SOURCE OF INCOME:	OCCUPATION:


NAME OF EMPLOYER/BUSINESS:	NATURE OF WORK:

AMOUNT: Php 1,998.00 PAYMENT CAN BE MADE THRU:
ECPay (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
Credit Card
PayMongo
Over-the-Counter 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
Bills Payment 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
Cashier Direct payment to the Cashier's office 8th Flr. The World Centre Bldg. 330 Sen. Gil Puyat Avenue, Makati City

RxER Online Application