My MediCard Online Application
FOR APPLICANT
 
FAMILY NAME: FIRST NAME: MI:
 
BIRTHDATE: SEX: NATIONALITY:
(MM/DD/YYYY)
 
CIVIL STATUS: HEIGHT: WEIGHT:
 
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:  
*** ALL FIELDS ARE REQUIRED
 
 
CLIENT/PAYOR
 
FAMILY NAME: FIRST NAME: MI:
 
RELATIONSHIP TO APPLICANT: TIN: SSS:
 
SOURCE OF INCOME: OCCUPATION: NAME OF EMPLOYER/ BUSINESS:
 
NATURE OF WORK:    
   
 
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PAYMENT
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AMOUNT: Php 3,600.00    
   
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PAYMENT CAN BE MADE THRU:


paypal

     

    Kindly deposit the payment in any of the following banks:
  • Account Name: Medicard Philippines, Inc.
  • RCBC - (Saving Account no : 1279940454)
  • Banco De Oro (Current Account no : 001388015346)
  • UnionBank (Checking Account no : 001240014688)
  • Please email a copy of your deposit slip to mymedicardpayment@medicardphils.com
    Kindly bank tranfser the payment in any of the following banks:
  • BDO Acct no.: 001388017802
  • Metrobank Acct no.: 727053319-8
  • BPI Acct no.: 1861-0084- 24
  • Please send a copy of the payment confirmation to mymedicardpayment@medicardphils.com

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


Please enter valid code



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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-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.

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