RxER Online Application

FOR APPLICANT
FAMILY NAME: FIRST NAME: MI:
 
BIRTHDATE: SEX: NATIONALITY:
(YYYY/MM/DD)
 
CIVIL STATUS: HEIGHT: WEIGHT:
 
EMAIL ADDRESS: CONTACT NO(s).: PLACE OF BIRTH:
 
 
*** ALL FIELDS ARE REQUIRED
  CLIENT/PAYOR
FAMILY NAME: FIRST NAME: MI:
 
RELATIONSHIP TO APPLICANT: TIN: SSS NUMBER:
 
SOURCE OF INCOME: OCCUPATION: NAME OF EMPLOYER/BUSINESS:
 
NATURE OF WORK:
 
  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

     

    Kindly deposit the payment in any of the following banks:
  • Account Name: Medicard Philippines, Inc.
  • Any RCBC branches (Account No.: 1279940454)
  • Any Banco De Oro branches (Account No.: 001388015346)
  • Any Union Bank branches (Account No.: 001240014688)

    (Over-the-Counter, Phonebanking, ATM, Mobile Banking and Online Banking)
  • Any Banco De Oro branches (Account No.: 001388017802)
  • Any Metro Bank branches (Account No.: 00727053319-8)
  • Any BPI branches (Account No.: 1861008424)
  • Any Union Bank branches (Account No.: 101240140960)

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


Please enter valid code


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-policy 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 Accept the Terms and Conditions.