I hereby apply for membership of the Proposed Member below in the health care program of Kaiser international healthgroup, Inc. (Kaiser) I agree that this Application and my declarations and answers below, shall be the basis, and deemed part of the contract between Kaiser and myself. I have never: a. Availed of any medical I surgical consultation or treatment?
I hereby apply for membership of the Proposed Member below in the health care program of Kaiser international healthgroup, Inc. (Kaiser) I agree that this Application and my declarations and answers below, shall be the basis, and deemed part of the contract between Kaiser and myself. I have never: a. Availed of any medical I surgical consultation or treatment?
I hereby apply for membership of the Proposed Member below in the health care program of Kaiser international healthgroup, Inc. (Kaiser) I agree that this Application and my declarations and answers below, shall be the basis, and deemed part of the contract between Kaiser and myself. I have never: a. Availed of any medical I surgical consultation or treatment?
MEMBERSHIP APPLICATION H E A L T H G R 0 u p . N c I hereby apply for membership of the proposed member below in the Health Care Program of Kaiser International Healthgroup, Inc. (Kaiser) described herein subject to the Contract Provisions set forth in this Application. I agree that this Application and my declarations and answers below, written by me or under my direction, shall be the basis, and deemed part of the contract between Kaiser and myself Proposed Member: Last Name - First Name Middle Name Sex Civil Status Height Weight Age Date of Birth Place of Birth Home Address Province/City Region Zip Code Home Tel. No. Port of Entry (if Seaman) I Destination Mobile No. Country (if OFW) Exact Occupation: Employer's Address: TIN No. Office Tel. No. Email Address Are you a Philhealth Member? D Yes Philhealth No: Employer: D No Owner I Payor (if the Proposed Member is 10-17 years old) Last Name First Name Middle Name Sex Civil Status Height Weight Age Date of Birth Place of Birth Home Address Province/City Region Zip Code Home Tel. No. Port of Seaman) I Destination Mobile No. Country (if W) Exact Occupation: Employer's Address: TIN No. Office Tel. No. Email Address Are you a Phi lhealth Member? D Yes Philhealth No: Employer: D No Beneficiary Age Relationship to Owner Beneficiary Age Relationship to Owner Principal 3. 1. 2 . 4. Plan Data Plan Name I Long- OcoRE D RIDER I Mode of OspotCash 0Annual D Semi-Annual 0 Quarterly 0Monthly Term Care Benefit Payment First IPR/SATR I PR/SATR I Contract rnstallment No. Date Price Amount I Payment Ocash ocheck 0 Credit Card Payment Form Answer all the questions pertaining to the Proposed Member or Owner I Payor (if the Proposed Member is 10-17 years) by checking appropriate box. 1. Have you ever: a. Availed of any medical I surgical consultation or treatment? b. Known of any impairment in your health? c. Been hospitalized and/or undergone surgery? d. Tested positive for antibodies to AIDS/hepatitis? e.Been advised to have any diagnostic test, hospitalization or surgery which was not completed? f. Had any abrupt change in body weight recently? If yes, how much? 2. Do you take alcohol, cigarette, or any habit-forming drugs? If yes, indicate average frequency I duration: 3. Do you engage in any hazardous sport or vocation? 4. Are you presently covered by any hospitalization or medical plan? Have you applied for or received payment for sickness or injury? 5. Have you ever been rejected for insurance I health care plans or offered insurance at higher premiums? ..... .......... ... .. ................ .. 6. Are you taking regular medication or undergoing medical treatment or observation? .................... ............. .. ..... ..... ...... ..... ......... ........ .. . (For Women Only) 7. Are you pregnant? If yes, how many months?------ Date of last delivery: (Month) __ (Day) __ (Year) __ Abortion, miscarriage, abnormal labor I pregnancy? Details ------------------- Have you had a tumor or disease of the breast, uterus, or ovaries? If yes, details----------------- 8. Do you have a history of any of the following: (if yes, check box) Yes No DD DD DO DO DD DO DD DO DD DD DO DD DO DD DO D Asthma 0 Tumors or internal organs D Hemorrhoids & Ana Fistulae D Tuberculosis 0 Stone in urinary tract D Hypertension D Ear, nose, throat tumors D Cataracts, Glaucoma 0 Convulsion (epilepsy) D Prostate problems D Varicose veins D Hernia (ascuired) D Diabetes mellitus D Liver disease D Collagen disease D Injuries from accident/assault D Cradiotomy 0 Cancer D Endometriosis D Diseased tonsils D Gall bladder stone D Kidney I urological disease 0 Cardiovascular diseases D Hyperthyroidism I goiter D Sinus requiring surgery D Gastric or duodenal ulcer D Buerger's disease D Arthritis & bone disease D Benign new growths D Cerebrovascular accident D Central nervous system lesions D Malignancies & blood dyscrasias D Single I multiple organ failure D Spinal stenosis If you answered Yes to any item of the questionnaire, please give details: Name & address of personal physician:------------ Date & reason of last consultation: _____________ _ Treatment given I medication prescribed: ----------- Medication being taken:----------------- Revision date: August 2010 Regions: Metro-Manila I Luzon I Visayas I Mindanao 5 243-517-251-000 F Married Saudi Arabia Nurse P.O. Box 7897 Riyadh, 11159 +96611477714 Prince Sultan Military Medical City