My MediCard Online Application
FOR APPLICANT

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:
(MM/DD/YYYY)
 
CIVIL STATUS: HEIGHT: WEIGHT:
 
EMAIL ADDRESS: MOBILE NUMBER: 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:    
   
 
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 havent 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.
 
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PAYMENT
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AMOUNT: Php 3,600.00    
   
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PAYMENT CAN BE MADE THRU:



     


Account Name: Medicard Philippines, Inc.
Bank Account Number
RCBC 0000-0012-7994-0454
BDO 0013-8801-7802
UnionBank 1012-4014-0960
BPI 1863-1765-37
Metrobank 270-7-270-53319-8

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 Republic Act 10173 also known as the Data Privacy Act of 2012, we need your Consent to allow us to collect and process your information. We will only disclose and share your personal and health information with your Company and its agents or brokers (if applicable), your own agent or broker (if any), with MediCard's officers, directors, employees, agents, consultants, contractors, representatives, affiliated companies within AIA Group, and recognized service providers which include MediCard's accredited hospitals/clinics, physicians, diagnostic service centers, and other allied health professionals who may also be responsible in rendering appropriate medical services to you.

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 you may visit www.medicardphils.com/privacy-statement/ 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 Memorandum of Agreement.

 To continue the application, please tick the box to show that you read and consider that you agree to give your Consent to us.