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Application Form
Application Form
HE Healthcare Corporation
PLAN TYPE PLATINUM PLUS PLATINUM GOLD SILVER BRONZE (Not applicable for Individual, Family & Group)
MODE OF PAYMENT ANNUAL SEMI-ANNUAL QUARTERLY MONTHLY (Not applicable for Individual, Family & Group)
PRINCIPAL/PAYOR
LASTNAME FIRSTNAME MIDDLE INITIAL EXTENSION NAME: AGE DATE OF BIRTH (M-D-Y)
CIVIL STATUS NATIONALITY HEIGHT (FT. IN.) WEIGHT (LBS) GENDER BLOOD PRESSURE
CONTACT PERSON & MAILING ADDRESS (NUMBER, STREET, VILLAGE, BRGY, CITY, ZIP CODE) OFFICE PHONE NO: FAX NO:
(IF UNDER AN AGENT/BROKER PLEASE INDICATE AGENTS/BROKERS ADDRESS)
YOUR SPOUSE
NATIONALITY JOB TITLE NAME OF OFFICE BUSINESS NATURE OF BUSINESS BLOOD PRESSURE
PROPOSED MEMBERS
W
H PHILHEALTH
G E
FULL NAMES OF E
E I
APPLICANTS A I
N G CIVIL
(Arrange Name IF APPLYING BIRTHDAY G G DENTAL JOB
RELATION D H BLOOD STATUS
Chronologically Based on (M-D-Y) E H COVERAGE TITLE NON
E T PRESSURE MEMBER
Age) T MEMBER
R (LBS)
(FT.IN)
YES NO YES NO
YES NO YES NO
YES NO YES NO
YES NO YES NO
YES NO YES NO
YES NO YES NO
FOR FAMILY AND GROUP ACCOUNTS: 15 DAYS OLD UP TO 21 YEARS AND 5 MONTHS OLD ARE ACCEPTABLE AGES FOR MINOR DEPENDENTS. CHILDREN WHO ARE 22 YEARS OLD AND ABOVE
WILL BE CONSIDERED AS INDIVIDUAL APPLICANTS.
DEPENDENTS PLAN TYPE PLATINUM PLUS PLATINUM GOLD SILVER BRONZE (Not applicable for Individual, Family & Group)
MEMBER NON MEMBER (Non-Philhealth member will shoulder for the Philhealth portion)
PHILHEALTH (PRINCIPAL)
1e. The genito-urinary system – such as renal colic, stone, bladder or kidney disorder, stricture, prostate disorder, syphilis, or venereal disease, etc.?
1f. The metabolic system – such as diabetes, gout, thyroid or adrenal disorder etc. and immune system disorders including acquired immune deficiency syndrome
(AIDS), AIDS-related complex (ARC) etc.?
1g. The musculo-skeletal system – such as back sprain, neck or back disorder arthritis, fractures, slipped disc, dislocation, joint problems, physically handicapped,
etc.?
1h. The respiratory tract – such as asthma, tuberculosis, spitting or coughing blood, allergies, emphysema, lung/chest disease of any kind, etc.?
2. Has any proposed member/s ever received a medical advice or treatment for, or ever had any known indications of any breast condition, infertility or other
female problems?
3. So far as you know, is a proposed member/s now pregnant?
Expected delivery date: (M-D-Y) __________________________
3a. If YES, is caesarean section anticipated?
4. Has any proposed member/s ever received medical advice or treatment for:
4a. Disease of eyes, ears, nose or throat?
4b. Any skin disorders, cancer, psoriasis, keratosis, herpes, etc.?
4c. Cancer?
4d. Tumor?
4e. Alcoholism or drug dependency?
4f. If YES to 4e, is he a member of a support group?
5. Has any proposed member/s ever had any:
5a. Hospitalization/Surgery?
If YES, please give details ____________________________________________________________________________________________
6. Any congenital disorders?
I HAVE READ THE MAXICARE APPLICATION FORM, CONDITIONS OF ENROLLMENT AND AUTHORIZATION STATED
ABOVE AND FULLY UNDERSTAND AND AGREE TO THEM.