MAXICARE HEALTHCARE CORPORATION

Maxicare APPLICATION FORM

For BANGKO SENTRAL NG PILIPINAS
C Y January 1, 20 19 - D ecembe r 3 1. 20 19
PINK

EXTENDED DEPENDENTS-PARENTS OF MARRIED EMPLOYEES

DEADLINE OF SUBMISSION TO ADMINISTRATIVE OFFICERS: January 18. 2019
Application forms submitted after the deadline will no longer be acc epted .

PART I. EMPLOYEE ltlFORMATION

PLEASE Fill UP All FIE LDS COMPLETE[_y___M_u_s_t_b_e_
lvn_e_w_n-·tt_e_n_o_,-,,-n-.n-ted In black Ink fnle a s e refer lo lhe enrollment auldellnes nrovld e d to vour AOJ:
EMPLOYEE NAME: Employee ADDRESS Number, Slreel, VIiiage, Barangay, City • :,
LaslName, FlrslName, M.1 . No. /2, Dries uf-· , C0tme,IJ~ M(NJ, 8r,!J'j· J'a ,,~~ , ,
foLo<;, , y".s-ofH , O•f!. . Jr" f3 go3C, B0tC--OOr c,,·,Jy G,;1'./e
I
I
Conlacl Information
I Civil Status
o, -
Sex #of Branch and Depart~enl
Birthday Age
{Month-Doy-Year} / Children .BJ'P - fflo.Nl /0. Te l #_ / Lo'l,dli 7e: 0 '-"2,/3/.'°j 17- '[ 1J 11, ' "
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Are you enrolling

Dependenls Addllional Philhealfh
already Birthday Civil (P 2,400) Please check box
Full Names of Dependents lo be Enrolled Age Sex Relationship if a pplica ble
updated wllh (Mon th-d Status
/Arra nge No me Chronologically Based on Age) HRMD? oy-yeo r) YES
(YES or NO) Plus P2.400 per NO
deoendenf

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► Ang "Additional Phrlheatlh " ay para so mga dependents no wafang phrfheaffh benefit (hatrmbawa, anak no edad 2 1 y.o pataa, of mogulang no 60
y.o pababa na wafang trabaho) . Kung ang dependent ay mayroon nang phi/health benefit, hindi no koilangan mag-enroll ng "additional
Philhealth ".
► Payment for "Additional Philheatlh" doe,n 'f automatically enrott members to Philheatth. ti i• non-lran,fe"abfe, non-pro-ratable and non-refundable.
► In case there is o valid reason of non-enrollmen t o f cerlo in depende nts, please refer to Porl IV #3 of Eligibility Guidelines for the required
d ocumentation to supporl non-enrollm ent of dep endent

I PARTII. PLANS & PREMIUMS

"Please check your prefe"ed ptan {one pion only)

Pi!<N PLAN MAXIMUM ANNUAL MEMBERSHIP FEE

Please TYPE BENEFIT LIMIT ROOM& BOARD /per d e pendent)
chec~. (MBL)
For below For 66-70
66 years old years old

d Gold I

Silver 1
P 200.000

P 200,000
ROOM RATE up lo Php 2,000/day or REGULAR PRIVATE ROOM w hichever is hig her

ROOM RATE up lo Php 1,200/day or SEMI-PRIVATE ROOM w hichever is higher

P 23,980

P 21 ,535
P 47,960

P 43,070

G old 2 P 150.000 ROOM RATE up lo Php 2,000/day or REGULAR PRIVATE ROOM w hichever is higher P 22.101 P 45,414

Silver2 P 150,000 ROOM RATE up lo Php 1,200/day or SEMI-PRIVATE ROOM w hic hever is highe r P 20,168 P 40,337

Maximum Benefit Umit is the maximum lia bility fhot Maxicore shall assume p er illness/injury per year o n a certain Mem ber. An illness a nd any of its compficotions
d iagnosed by the attending doctor sha ll share some MBl. PhllHeallh benefits are on lop of the member's MBl.

I PAJIT Ill. GUIDELINES

I. Pa re nts of Married Employees may be enrolle d on the following conditions:

a. Premium must be paid directly by the Employee through our accredlled banks - BPI, PNB, Securlfy Bank, BOO, Equicom, Melrobank, RCBC, Union
Bank and Maybank. Please use bills payment slip wllh fhe tt. details:
Company Name: Moxicore Healthcare Corporatio n,
Subscriber's Account No: FR00000000055626
Subscriber's Name: Emp loyee No me '. Ba ngko Sentro l ng Piliplnos .
!2.__Proot o f pay ment lb ills p a yment slip) m usl be o ltoc hed lo application form prior activation . Poymen l shall be mode o n or b e f01e 1<, n yqy 1/l. ;<ll -'
Failure to pay on the sold dead line will automollcolly cancel th e applica tion o l lhe exte nded dependenl /s.
c Port IV Eligibility o f the e nro llment g uidelines Is met.

All d ep e ndents per tamlly mu1t b e e nro lled under I pio n type ,

3. N° caac,Uatlon olrotmb,c,blp within lh• c0 v•raa, v•ar-

4. AII applic ation lorm1 o l ornolloe, wholher oxisllng or ne w membe1s wlfh no !PtG IUG plan lodlcgf•d will b• procf1Sf<1t11110N1d ynd11 fbt lowt:11plqn
5. AU o•w 0nd txl•llDA ro•robtt• wtth or wHhoyl chqng11 lo lb• coyt[qg• wvll HH-ug gppHcgHon 12rm11 111llu1 u lu ~ullmll tho a pphcatlvn 101111 in 1110
prescribed d eadline 1holl mea 11 ca ncoio llon n l momborsl1lp. Maxlc m 11 1I,a li 111 11 8 u lo l ler o l c ,>111plln11ct1 t,,, I11e n1be,s \\slh pendi110 1e<1ukements. l a te
submls.1011 o f A/F will b 0 aub)ecf or approval

6. Membe,s shou ld provide, llialr .G.9.lll.Plta billing acld1011 a11d c o 11 ta c l nu111uo11, ol l w 1wlu, a p p lh.: ullon to,m shall b e llulJ ponding
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 7. Phllheatth Qualllled Dependents
• The legitimate spouse who is not a me~ber of Phllhealth .
The unmarried and unemployed leg1llmale, legltlma led, acknowledged and llleglllmale c hildren appearing in the birth cerlitica te . legally
adopted or stepchildren be/ow twenty-on• (21) year, or age.
Children who are lw<tnly-on• (2 IJ yeart old or above but su ffering fro m congenital dlsablllly, either physical o r mental. or any disability acquired
before the age of 21 that renders fhem totally dependenl on the me mber for supparf.
The parents who are J/xly (60) years ofd or above who ore not enrolled members o f Phtlhe allh whose monthly Income ts no t more than One
Thousand Pesos IP I .000.)
Phi/health enrol/men# Is non-transferrable.

All new members wifh unprocessed application forms that have Incurred avallmenls within the enrollmenf will be e ligible tor reimbursemen fs subject to
8.
evaluation and Moxicore rates .

Maxicare will bill back the cost of availment to guardian/employees if in case an exisllng member/s that are no! for renewal by CY 2019 had availed
9.
within the enrollment period starting January l. 20 19 and until suc h time all ren ewal terms were validated.

10 _ Continuous coverage for th e extended dependents (dependents o f married employees prior to marriage) shall be valid until December 3 1. 20 19.

11. Payment for over aged dependenf/s shall be made on or before lanuary 18 20 19.

--! PART IV. ELIGIBILITY

Direct Dependents Ellalbllltv Direct Dependents Ellglbllilv- Extended Deoendenls Hierarchy of Enrollment
Spouse 66-70 yrs. old : Single and
Spouse below 66 yrs. old as of effective date; Single and unemployed children from 22 to 30 Spouse. I'' c hild, 2°•
For Married c hild . 3"' c hild . e tc .
unemployed c hildren fro m birth to below 22 yrs. o ld as of effective yrs. old .; Parents
Employees Parenls
dale (Please see requirement below for
New Enrolllna Dependents)

l . Enrollment Is open lo new and existing parent dependents of married employees only. On the tlrsl year, dependent shall have no coverage for Pre-existing
Conditions. This benefit shaA be covered on the second year onwards; however, there should be a continuity ol coverage.

2. Ellgiblllty for Pre-mature babies

Only children with full term births. meaning those born at least 37 weeks from conception, shall be given coverage. Children born prior to such p eriod shall
have lo wait for !hot 37th week which marks the period from which their minimum eligibility age shall be counted from , in order to gain coverage.

3 . Unless there is a valid reason for the non-enrollmenf of certain dependents (i.e. currently enrolled in another heallhcare coverage, abroad, overage,
dece?sed, and legally separated} employees of Bangko Senfral ng Piipinos should enroll their eligible dependents based on the hierarchy guidelines
mentioned above. Furthermore. sufficient documentation shall be requested by Maxicare from the employee to validate the non-eligibility of the
dependent 11. e. photocopy o f HMO card or certification if with another HMO or sell-insured, death certificate for deceased, birlh cerlificate for Overage,
legal document confirming separation, and certificate of employment abroad or copy of Passporl/VIS A for non-resident dependent).

4 - Of her special accommodation: Married Employees with spouses who are also employees of BSP may enroll their parents up to 70 yrs old provided no chfld
dependent is erigible within the current coverage period . Extended coverage accommodation will not apply to Sibrings fl ln c ase both parents are not
eligible to be enrolled in the program) . The existing dependent cannof be replaced by another dependent In case of death. Bills payment slfp as proof of
payment must be attached upon submission of appllcatlon form.

LDouble membership of dependents shall not be allowed .

6. Rates indicated herein are not applicable to direct adult dependents that are 66-70 years old. For the said depende nts, please use form for 66-70 years old
adult dependents .

7. Accommodation /or extended dependents regardless if /he other spouse is working in another company until December 3 1, 20 19.

8. All outstanding balances during the previous coverage must be se ttled. Otherwise. all member of the family will not be able to enroll & renew appfication.

I PART V. CERTIFICATION/AUTHORIZATION
CERTIFICATION

I hereby certity Iha/ all information contained in this application form are /rue and complete lo the best of my knowledg e, and that any misrepresentatio n as to

material tact indicated herein shall be a cause for the cancellation/discontinuance of the HMO covera ge.

AUTHORIZATION/UNDERTAKING

I hereby voluntarily enroll my dependenl/s with Maxicare Healthcare Corporation .

I hove likewise read and understand the guidelines indicated in the application form .

I a~o commit and undertake to settle any and all obligations that I may incur in connection with the Healthcare coverage in my personal capacity as well a s in
behalf of all my Erigible Dependents and Extended Family Members on or before January 18 2019. I understand that failure on my part to seffle my o bligation
on or before on the said dale shall mean cancellation healthcare coverage.

DATE

Important Notice: Ma xicare will only activate the membership in the 2019 coverage if application form has been provided on or before the said deadline. l!2,
case the member has not received the new ID card , the a vailments will still be a ccommodated provided they present th eir old Maxicare c ard and
Identification c ord. For any concerns, please contact 908· 6900 focal I 125.

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 DEED OF CONSENT

In reference to my and/or my dependenf/s ' h~althcore plan procured by the Company, I hereby certify that I and m
understood the Summary of Coverage a~d Be~ehfs ~I the Service Agreement executed by Maxlcare Healthcare Corporation i"
depende,~t/s have read and
including all procedures. benefits. exclusions. hm1tot1ons and condtlions contained therein , and agree lo be bound thereb Maxlcare ) and the C<;>~pany
services of Moxicore, 1 and my dependent/s acknowledge and agree to abide by all the membership terms and conditions y . . Furthe_
rmore,_by ava1hng the
https://maxicare.ph/member-terms. published via Moxtcare website at

In executing this document and in affixing my signature hereto, I confirm that :

1 ':'gree a~d understand that in the co~rse of pr':'viding services to me or m_v dependents, Maxicore _s~all engage the services of, and/or intera ct with other
third parties, such as, but not l1m1ted to ,ts parent company, affthated companies, subs1d1anes, financial advisors affT 110 I d th' d ·.
independent/non-affiliated third parties and service providers, whether local or foreign [collectively referred fo as "Representatives:'). e tr parlies or

I and my dependent/s have freely. knowingly and voluntarily given my consent for Maxicare and its Representatives to:

Obtain, collect , examine, process, and store copies o f my and/or my dependents ' personal information, including sensitive personal information, privileged
information, medical records or any other information or material. i.e ., picture, voice recording , fingerprints, and etc .. relative to my (and/ or my dependents')
hospitalization. consultation. treatment or any medical advice in connection with the benefit/ claim availed under the Agreement as may be deemed
necessary by Maxicare. Except as otherwise staled hereon, any information obtained relative lo the authority herein given shall be stric tly confidential. The
extent of the collection and processing shall be necessary and incidental to the performance of the services contemplated in the Agreement.

Disclose such information to the Company, its representatives, agents and brokers, Maxicare and its Represe ntatives, including the service providers which w ill
perform the services contemplated in the Agreement. for any legitimate business purpose as Maxicare may deem appropriate, including but not limited to
outsourced processing o t Maxicare transactions, profiling or historical statistical analysis, providing advice or information which Maxicare and its
Representatives believe may be of interest to me or the Company, to effectively administer or manage my account, enhance customer services. or to
communicate with me for any marketing purposes.

Processing is hereby understood to include any operation or any set of operations pertormed upon personal information including, but not rimifed to, the
collection . recording, organization, storage. updating or modification , retrieval, consu ltation, use, consolidation, blocking , erasure or destruction of data.
Processing would include both manual and automated handling of personal information and storage and data transfers using various means including but not
flmited to physical methods as well as electronic via information and communications systems employed by Maxicare and its Representatives.
I have been duty authorized by my dependent/s lo sign and execute any and all documents and make representations for and in his/their behalf as if the
same were personalty done by him/them.

I hereby warrant that we understand our rights and obligations pursuant to the Data Privacy Act and its implementing rules and regulations. I and my
dependents understand that we retain the right to: be informed. to object, to access, to complain, to rectify, to request for filtering of certain information and
to corresponding damages in case of violation of our rights within the corresponding limitations as set forth in the pertinent tows.

I and my dependents hereby represent that , in order to provide the services contemplated in the Agreement. the authorities herein provided shall be valid and
existing during the term of the Agreement. including any extensions thereof. and until necessary for the establishment. exercise or defense of any claims arising
from the said Agreement.

I and my dependents hereby agree l o hold Maxicore and its Representatives tree and harmless from and against any and all suits or claims. actions. or
proceedings. damages, costs and expenses, including attorney' s tees, which may be filed, c harged or adjudged against Maxicare or any o f its directors.
stockholders. olficers, employees, agents, or Representatives in connection with or arising from the use, processing and disclosure by Moxicore or its
Representatives of the aforementioned information pursuant to Moxicare reliance on my and my dependent's representation and warranty that Maxicore, the
Company, and their representatives hove the authority to examine. use. process. store, share. or disclose. as the case may be. said information for the
above-mentioned purposes.

Moxicare reserves the right to amend the Membership Terms and Conditions at any time without need of prior notice or approval, and any queries related
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XAM~EE DATE

For Dependent/5 of Legal Age: By affixing your signature below. you freely. knowingly and voluntarily given your consent as described in this documenl.

Name Maxie are Membership No. Email Address Signature

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