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KAISER INTERNATIONAL

HEALTH CARE PROGRAM


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

Application # 800013308721

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