VOLUNTARY
***NOTE: NOT UPDATED MARITAL OR TAX STATUS WILL NOT BE ACCEPTED HENCE, YES___ NO___
NON-ENROLLMENT OF DEPENDENT/S
MAXICARE HEALTHCARE CORPORATION
CORPORATE ACCOUNT APPLICATION FORM FOR DEPENDENTS
PART I. EMPLOYEE INFORMATION
Must be type written or printed in black ink.
EMPLOYEE NAME Last Name, First Name, M.I. (REQUIRED): Employee No. (REQUIRED): DEPARTMENT / BRANCH (REQUIRED):
✔ ✔ SITE (REQUIRED): ✔
CABARLO RYAN JOY D
930358 ✔ I
SALES/ SITEL
SITE
TARLAC
HOME ADDRESS Number, Street, Village, Barangay, City (REQUIRED): Birthday Month-Day-Year Civil Status Sex Mobile Number Personal email
007 MCARTHUR HIWAY (REQUIRED): DECEMBER 05, (REQUIRED): (REQUIRED): (REQUIRED): Address:
POBLACION I, 1978 MARRIED MALE rjcabarlo78@yahoo.c
MONCADA, TARLAC 09054466292
om
✔ ✔ ✔ ✔
PART II. DEPENDENT INFORMATION
If Enrolling Full Names of Employee’s Dependents Gender Civil Status Age Relationship Birthday
please check Month-Day-Year
Yes No ✔
✔ BETHSHEEBA M SERRANO - CABARLO F Mar ried SPOUSE 12 30 1988
PART III. ELIGIBILITY
A. ELIGIBLE DEPENDENTS AND AGE REQUIREMENT B. DOMESTIC PARTNERSHIP C. ADDITIONAL DEPENDENTS (Voluntary)
B.1 Common law partners
B.2 Same gender partners Note: Subsequent dependents shall be at member’s own account.
Requirements :
Eligible Dependents for enrollment as enumerated below.
Direct Dependents: For Single Employees: Parents and Siblings, Partner (max of
3) For Single Parent Employees Children and Parents (max of 3)
Both principal and dependent are single status- has not contracted
Single
Employees: For Married Employees: Children (max of 3)
Parents (up to 65 years old) & Sibling max 3 (15 days to 21 years old) marriage in Philippines or elsewhere
Single Parent With respect to live in partners other than the same gender there Qualifying Age Requirement
Employees: should be no legal impediment to marry one another Parents : 66-80 years old
Parents (up to 65 years old) and Children max 3 (15 days to 21 years old)
Living together in the same residence Spouse : up to 80 years old
Married Employees: Both gainfully employed and Siblings : 15 days old-23 years old
Both are mentally competent Children : 15 days old-23 years old
Legal Spouse up to 65 years old, up to 3 Children from 15 days old to 21 years old
(single and not employed) Domestic and Same Gender : up to 80 years old
Documents
Same gender/Common law/Domestic Partner: Certificate of cohabitation (minimum of 3 years) Furthermore, sufficient documentation shall be requested by Maxicare from the
employee to validate the non-eligibility of the dependent (i.e. photocopy of HMO
Certified True Copy/PSA of Cenomar for Filipino Nationals
Parents (up to 65 years old), sibling (up to 21 years old), Partner
(Employee and Partner) card).
Barangay certificate of residency of employee & employees partner
Birth Certificate ( Employee and Partnesr) PSA
Copy Affidavit of joint partnership
*** Authority to Deduct (ATD) and Premium rates are available at the Maxicare
CCR office.
PART IV. CERTIFICATION
AUTHORIZATION FOR DISCLOSURE OF PERSONAL HEALTH INFORMATION
I hereby authorize any healthcare facility, physician and surgeon, or other healthcare professional to provide Maxicare Healthcare Corporation its agents or employees, all
information pertaining to any examination or treatment done to me, or to any illnesses, injury or condition that I have had at any time in the past or in the future up until
the expiration of this authorization. I understand that this information is collected in connection with the evaluation and processing of an application for coverage of a
change in benefits, or to determine eligibility for benefits. This authorization is valid for the entire period of my membership. A photocopy of this authorization is as valid as
the original. My authorized representative or I am entitled to receive a copy of this form.
I hereby certify that all information contained in this application form are true and complete to the best of my knowledge and belief, and that any misrepresentation as to
material fact indicated herein shall be a cause for the cancellation/discontinuance of the HMO coverage.
As a legal guardian of my dependents who are below 18 years old, I hereby sign on their behalf:
✔
✔ __________RYAN JOY D. CABARLO_ _________ ____JUNE 10, 2020___
PRINTED NAME AND SIGNATURE OF EMPLOYEE DATE
REMINDERS:
For Legal Spouse Dependent/s: Marriage Contract and Birth Certificate from PSA
What are the requirements and supporting documents in enrolling my dependents?
For Same Gender Partner: Birth Certificate of Dependent/s Barangay Certificate of
Co-Inhabitation, Birth Certificate of Dependent/s, Certificate of No Marriage or if
For solo parents – make sure to secure a solo parent ID from DSWD. Married – Notarized affidavit of separation (or Affidavit of no longer leaving
together for 8 years or more)
Be ready with other/additional requirements for the enrollment of your new/additional dependents For New Born Dependent/s: Birth Certificate from PSA For Domestic/Common Law Partners: Birth Certificate of
Dependent/s, Certificate of
No Marriage or if Married – Notarized affidavit of separation (or Affidavit of no longer
leaving together for 8 years or more)
What are the requirements and supporting documents in enrolling my domestic partner?
*note though that in the event of any insurance monetary
claim *subject for further review and additional inputs - HCE
Please see below for your reference Conditions for enrolling your Domestic Partner
• Both the principal member and domestic partner are legal age but not more than 65 years
old and no legal impediment to marry; has not contracted marriage in the Philippines or
elsewhere; not related by blood whether legitimate and illegitimate, up to fourth degree.
• Shared a single, intimate, committed relationship of mutual caring; intend to remain each other's sole
domestic partner indefinitely;
• Residing together in the same residence
• Both are mentally competent to consent or contract.
Documentary Requirements:
• A joint Affidavit of Domestic Partnership certifying that all criteria are met;
• Barangay Certification of Co-Habitation stating that principal member and domestic partner live in the
same address including the duration ( Minimum of 3 Years) of their residence therein; • Certified Copy / PSA
copy of Birth Certificate
• Certified Copy / PSA copy of No Marriage
://hmo.enrollment.form/Nov2019
