My MediCard Online Application
Are you assisted by an agent :      YES       NO
   
     
CLIENT/PAYOR

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)
PLACE OF BIRTH: RELATIONSHIP TO APPLICANT: TIN:
 
SSS: SOURCE OF INCOME: OCCUPATION:
 
NAME OF EMPLOYER/ BUSINESS: NATURE OF WORK: MOBILE NUMBER:
GOVERNMENT ID    
   
 
PAYOR ADDRESS (UNIT/BLDG.,NUMBER,STREET,SUBDIVISION,BARANGAY):
 
CITY: PROVINCE:  
 
*** ALL FIELDS ARE REQUIRED
 
 
FOR APPLICANT
 

 
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:  
 
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:



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-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 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.