HMO ONLINE APPROVAL FORM
The following questionnaire is a comprehensive look at your health. It will take about 5 minutes to complete.
DISCLAIMER
Please allow us at least 24hours to process your request once submitted. Also, please be reminded that requests made beyond *office hours will be processed on the next business day.
HMO BUSINESS HOURS
8:00AM to 5:00PM - Monday to Sunday (Approval time is 1 to 2 days form the date of scheduled)
Purpose:
*
OPD Check-Up
Procedures / Diagnostic
Health Card Provider:
*
Amaphil
Eastwest
Etiqa
Flexicare
Intellicare
Avega
Kaiser
Medasia
Medocare
Sunlife
CarehealthPlus
Caritas
Cocolife
Equicom/Medilink
HMI
HPPI
Medicard
Pacific Cross
Philcare
Benlife
Generali
Getwell
Insular
Lacson
Valucare
Wellcare
Company (Principal Card Holder)
*
Card Number:
*
Account Number:
*
Requesting Doctor
*
Full Name
*
First Name
Last Name
Address
*
BLK, Ph, Street
Barangay
Municipality/City
State / Province
Postal / Zip Code
Gender
*
Male
Female
E-mail
example@example.com
Phone Number
*
-
Area Code
Phone Number
Back
Next
Ano ang dahilan ng konsultasyon.
*
Doctors prescription
*
Browse Files
Cancel
of
Health Card
*
Browse Files
Cancel
of
Valid I.D with Birthdate
*
Browse Files
Cancel
of
Finish
Should be Empty: