APPLICATION FOR IPER CARE PROGRAM
NOTE:
TO FACILITATE PROCESSING OF THIS APPLICATION, PLEASE ACCOMPLISH THIS FORM COMPLETELY AND SUBMIT THIS WITH YOUR SIGNED CONFORME ON THE RE-AFFIRMATION BELOW.
PRE-APPROVED APPLICATION FOR 18-50 YEARS OLD PRINCIPAL ENROLLEES-Medical Examination is only REQUIRED for enrollees age 51 to 59 years old. in Partnership with
           *51-59 years old, Please call PHILCARE Taguig Office at (+632) 802-7333 loc. 19082
                      PHILCARE Cebu Office at (+6332) 231-5140
      
  
*Application and IDs will be processed within 7 working days from PhilCare's receipt of complete requirements from Rent.ph Agent Name
*If the application has been approved and paid by:
A: 6th - 20th of the month, the effective date will be the first of the following month;
B: 21st - 5th of the month, the effective date will be the 16th of the following month.
    Part I
LAST NAME FIRST NAME MIDDLE NAME BIRTHDAY (MM/DD/YY) AGE
PERMANENT ADDRESS ZIP CODE TIN
House/Street City/Province Brgy/District Region
OFFICE ADDRESS RESIDENCE TEL. NO BUSINESS TEL. NO






House/Street City/Province Brgy/District Region
OCCUPATION/JOB TITLE NATURE OF BUSINESS EMAIL ADDRESS MOBILE NO PLACE OF BIRTH
GENDER  CIVIL STATUS  CITIZENSHIP  ESTIMATED TOTAL MONTHLY INCOME 
 
  HEIGHT WEIGHT   BMI

  cm kg   Result
NO. OF CHILDREN (SINGLE AND BELOW 21 YEARS OF AGE)
    Part II
IPER CARE PLUS - A health care benefit program that covers emergency cases at the hospital ER including admissions for emergency and elective cases. And coverage for out-patient emergency care.
TYPE OF PROGRAM
IPERCARE PLUS Regular Private

120,000 ABL
Semi-Private

60,000 ABL
Ward

50,000 ABL
ANNUAL RATES (VAT
INC.)/member
     *Above rates are VAT inclusive
     *Note: PhilHealth is REQUIRED
Additional Cost for Member (without PhilHealth coverage)
Annual: Php 2,688.00
Please attach payment slip and other required documents here.
Attachment (*.jpg, *.jpeg, *.jpe, *.png, *.tif, *.pdf) Official Receipt No. Total Amount
No files
     ABL - Annual Benefit Limit (Accumulated limit/member/year)
     *For other Products, Please call PHILCARE or check website www.philcare.com.ph
     *Please refer to PhilCare brochures for the detailed benefits and list accredited providers.
     Part III   
*Minor dependents from 6 months to 20 years old must be enrolled together with a principal member (both or either one of the parents)
FAMILY MEMBERS APPLYING FOR MEMBERSHIP DOB AGE SEX HT WT RELATIONSHIP TO PRINCIPAL/PAYOR OCCUPATION CITIZENSHIP
    
No Member
    
RE: LETTER OF RE-AFFIRMATION
Please be informed that I have read and understood the contents of the application and the limitations of my coverage.
I hereby certify that the data and other information stated herein are written by me or under my supervision.
I am submitting with this letter the accomplished application form and my initial payment.
I fully understand that Pre-Existing conditions and any of its complications are not covered by this healthcare program.
I authorize PHILCARE to transact directly with Rent.ph for the collection and settlement of applicable membership fees.
I understand that programs are subject to provisions under the General Exclusion of the Philcare contract.
I understand that hospitalization services should only be availed in PhilCare affiliated hospitals and should only be recommended by affiliated physicians.
8/19/2017
Signature over Printed Name of Principal Applicant Date
I agree and authorize the Company to use and disclose any information (collected or held) with regards to the matters pertaining to this application to enable the Company, its associated individuals, organizations or independent third parties, to provide advice or information covering products or services which the Company believes maybe of interest to me or to communicate with me for any purpose.
 
     
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