PHILCARE APPLICATION HEALTHLUXE PLAN

APPLICATION FOR INDIVIDUAL/FAMILY PLAN
PRE-EXISTING CONDITION (PEC)
INSTRUCTIONS:

INDIVIDUAL PLAN
Only one person can use the card (Only Principal adult or minor only)

ADULT only (18 y/o - 60 y/o):
✔Details should be on principal/payor part (skip 2nd page and sign the 3rd page)
✔If two or more adults will apply then one application form per adult (repeat the online application process)

MINOR only (15 days old - 17 y/o):
✔Details on principal/payor part should be the guardian of minor
✔Details on the dependent part (2nd page) should be the minor
✔Signature on 3rd page should be the principal/payor guardian of minor
✔If two or more minors will apply then one application form per minor (repeat the online application process along with the details of guardian principal/payor per application)

________________________________________________________________

FAMILY PLAN
1 or more person can use the card (Principal + Dependent/s immediate family 1st degree only)

SINGLE eligible dependents (either / or):
⦿Parents - up to 60 y/o only
⦿Siblings - 15 days old to 21 y/o only (eligible only if parents is 60+ y/o,deceased,ofw,hmo member)
✘you cannot mix dependent parents to siblings (vice-versa)

MARRIED eligible dependents (and / or):
⦿Spouse - up to 60 y/o only (can skip spouse if 60+ y/o,deceased,ofw,hmo member)
⦿Children - 15 days old to 21 y/o only

SINGLE PARENT eligible dependents (either / or):
⦿Parents - up to 60 y/o only
⦿Children - 15 days old to 21 y/o only
✘you cannot mix dependent parents to children (vice-versa)
APPLICATION FORM
PRINCIPAL / PAYOR*

First NameM.I.Last Name
ADDRESS*

House #, Street Name

Brgy, City, Province

CityState / Province

Zip Code
MOBILE NUMBER*
EMAIL ADDRESS*
OCCUPATION / JOB TITLE*
NATURE OF BUSINESS / COMPANY*
TAX IDENTIFICATION NUMBER (TIN)
BIRTH DATE*

MonthDayYear
Date
AGE
HEIGHT*
Example : 5'6"
PLACE OF BIRTH*
Calculation
TODAY

MonthDayYear
Date
HEIGHT BMI*
WEIGHT*
Example : 5'6"
CITIZENSHIP*

FilipinoOther
GENDER*
NO. OF CHILDREN*
CIVIL STATUS*

SingleMarriedWidowedSeparated
PLAN TYPE*

150K - Regular Private300K - Semi Private
MODE OF PAYMENT*

AnnualSemi-AnnualQuarterly
DENTAL RIDER?*

YesNo
PHILHEALTH MEMBER?: (If No, Fees will based on the Mode of Payment - Annual: 2,288 / Semi-Annual: 1,439 / Quarterly: 740)*

YesNo
MONTHLY INCOME*

10,000 or below10,001 - 20,00020,001 - 50,00050,001 - 100,000100,001 and up
PAYMENT OPTIONS*

Cash/OnlineCheckCredit CardCard (Over-the-counter)Card (Auto Debit Arrangement)
IF CARD PAYMENT (Auto Debit Arrangement)

Card Name

Card Number

DEPENDENT/S (if family plan)
DEPENDENT/S (skip this part if no dependent/s)
DEPENDENT 1
Full Name
BIRTH DATE DP1

MonthDayYear
Date
AGE DP1
HEIGHT DP1
Example : 5'6"
Calculation DP1
GENDER DP1
RELATIONSHIP TO PRINCIPAL / PAYOR DP1
OCCUPATION DP1
CITIZENSHIP DP1
DEPENDENT 2
Full Name
BIRTH DATE DP2

MonthDayYear
Date
AGE DP2
HEIGHT DP2
Example : 5'6"
Calculation DP2
GENDER DP2
RELATIONSHIP TO PRINCIPAL / PAYOR DP2
OCCUPATION DP2
CITIZENSHIP DP2
DEPENDENT 3
Full Name
BIRTH DATE DP3

MonthDayYear
Date
AGE DP3
HEIGHT DP3
Example : 5'6"
Calculation DP3
GENDER DP3
RELATIONSHIP TO PRINCIPAL / PAYOR DP3
OCCUPATION DP3
CITIZENSHIP DP3
DEPENDENT 4
Full Name
BIRTH DATE DP4

MonthDayYear
Date
AGE DP4
HEIGHT DP4
Example : 5'6"
Calculation DP4
GENDER DP4
RELATIONSHIP TO PRINCIPAL / PAYOR DP4
OCCUPATION DP4
CITIZENSHIP DP4
DEPENDENT 5
Full Name
BIRTH DATE DP5

MonthDayYear
Date
AGE DP5
HEIGHT DP5
Example : 5'6"
Calculation DP5
GENDER DP5
RELATIONSHIP TO PRINCIPAL / PAYOR DP5
OCCUPATION DP5
CITIZENSHIP DP5
REQUIREMENTS

Kindly upload the files in clear copy:

DEPENDENT/S (skip if no dependent/s)
1. if Spouse - Marriage Certificate & Valid ID
2. if Parents - Marriage Certificate & Valid ID
3. if Child - Birth Certificate
DEPENDENT 1

Browse Files
If Spouse/Parents (Marriage Cert & Valid IDs) Cancelof
DEPENDENT 2

Browse Files
If Child (Birth Cert only) Cancelof
DEPENDENT 3

Browse Files
If Child (Birth Cert only) Cancelof
DEPENDENT 4

Browse Files
If Child (Birth Cert only) Cancelof
DEPENDENT 5

Browse Files
If Child (Birth Cert only) Cancelof

REQUIREMENTS
REQUIREMENTS
Kindly upload the file in clear copy:

PRINCIPAL/PAYOR
1. 1 Government Valid ID
Agent Name
Agent Name 2
DATE 3
Deliver to member
permanent address
Billing sent
Signed at
PRINCIPAL/PAYOR*

Browse Files
Government Valid ID Cancelof
SIGNATURE OF PRINCIPAL/PAYOR 2*

Clear
SIGNATURE OF PRINCIPAL/PAYOR 3*

Clear
By signing below, I certify that information given by me is true and correct and that any material misrepresentation or falsity therein shall be construed as act to defraud PhilHealth Care Inc. (PhilCare), and a sufficient ground for legal action and the rejection of my application and membership. I hereby authorize PhilCare to inquire about and investigate all declared information from whatever sources PhilCare may consider appropriate.

I agree that receipt of the corresponding membership fees by PhilCare does not constitute acceptance of my application until the corresponding application has been approved and my PhilCare membership card has been issued to me. Effectivity of the cards startrs 7 days from notice of the acceptance of my application. Any incident, illness or condition that occurs prior to Effectivity Date will not be covered.

Approval of this application is subject to the receipt of full payment, application for, photocopy of valid ID with signature. Further, I agree that the application form and related documents submitted to PhilCare will not be returned to me for whatever reason. In case of disapproval of my application, . the membership paid and remitted will be refunded to me by PhilCare. PhilCare is under no obligation to provide me with the reason for disapproval of my application.
I have read and understood completely the Terms and Conditions governing the issuance and use of the health card that I choose. I also reconfirm my agreement to the Declaration stated above*

Yes
SIGNATURE OF PRINCIPAL/PAYOR*

Clear
Full Name (First Name, Last Name)*
Signed at: (Location)*
Day Signed: *
Month Signed: *
PLEASE REVIEW ALL DETAILS IF ALL ARE TRUE AND CORRECT BEFORE SUBMITTING
Date

MonthDayYear
Date
A03
001
0903328
.a03
.001
.0903328

APPLICATION FOR INDIVIDUAL/FAMILY PLAN

APPLICATION FORM

DEPENDENT/S (skip this part if no dependent/s)

REQUIREMENTS