Name of Company Representative*
Number of Enrollees*
Principals/Sponsors who will enroll any dependents or beneficiaries are deemed to have secured the proper consent from the said dependents or beneficiaries that they have been designated as such.
Communications will be sent through your given email, mobile number, or address. Should you need to update any information or contact details, please get in touch with us via email to: email@example.com and copy furnish: firstname.lastname@example.org.
In compliance with Republic Act 10173 also known as the Data Privacy Act of 2012; We need your consent to allow us to collect and process your information. We will only disclose and share your information with our accredited health care providers who may also be responsible in rendering our services to you.
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 you may visit www.medicardphils.com/privacy or email email@example.com for more information.
By ticking the box, we will consider that you agree to give your Consent to us.
I have read and fully understood the terms of the Memorandum of Agreement.
A medicard representative will contact you soon