MEDICARD

HEALTH PLUS CARD

APPLICATION FORM

FOR APPLICANT FAMILY NAME FIRST NAME MI BIRTHDATE

SEX NATIONALITY
MALE
FEMALE
YYYY MM DD

CIVIL STATUS HEIGHT WEIGHT EMAIL ADDRESS CONTACT No(s).

SINGLE WIDOW / WIDOWER FT. IN. LBS.
MARRIED SEPARATED

PLACE OF BIRTH PRESENT ADDRESS: UNIT/BLDG., NUMBER, STREET, SUBDIVISION, BARANGAY, CITY, PROVINCE

CLIENT/PAYOR FAMILY NAME FIRST NAME MI PERMANENT ADDRESS: UNIT/BLDG., NUMBER, STREET, SUBDIVISION, BARANGAY, CITY, PROVINCE

RELATIONSHIP TO APPLICANT TIN SSS NUMBER

SOURCE OF INCOME OCCUPATION NAME OF EMPLOYER/BUSINESS NATURE OF WORK

EMPLOYED PENSION
SELF EMPLOYED OTHERS

The MediCard Health Plus Card entitles card holders to preventive health care services,
unlimited consultations with MediCard doctors plus discounts on laboratory and diagnostic
tests.

SPECIFIC BENEFITS INCLUDE: PLUS:

• Annual Physical Examination consisting of:

- Comprehensive Physical Examination • No age limitations
- Complete Blood Count • No pre-acceptance medical exam
- Urinalysis • Membership is already good for 1 year
- Fecalysis (Stool Exam)
- Chest X-ray
• Unlimited consultation with our general
practitioners, family medicine physicians,
internal medicine physicians, pediatricians ALL THESE FOR ONLY P1,100!
and gynecologists (except on maternity-
related consultations)
• 20% discount on all
laboratory / diagnostic
procedures
• Free one-time oral prophylaxis

NOTE:
Flat rate of P350 applies to consultations with specialists such as ENT, ophthalmologists, rehab medicine physicians,
etc. All benefits enlisted above can only be availed in any MediCard free-standing clinics.

DATA PRIVACY TERMS

In compliance with Republic Act 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 or email privacy@medicardphils.com for more information.

By agreeing with our terms we will consider that you agree to give your Consent to us.

SIGNATURE OVER PRINTED NAME