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Cooperative Health Management Federation: Enrollment Application Form (Eaf)

The document is an enrollment application for a health management federation, requesting personal and medical information from applicants such as name, address, medical history, and authorization to obtain medical records. It explains the application and enrollment process, requirements for membership, and privacy policies regarding personal data collection and use. Applicants must sign acknowledging their understanding of the application and authorizing their cooperative to process their enrollment.

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Geraldine Daquipil Tortal
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242 views

Cooperative Health Management Federation: Enrollment Application Form (Eaf)

The document is an enrollment application for a health management federation, requesting personal and medical information from applicants such as name, address, medical history, and authorization to obtain medical records. It explains the application and enrollment process, requirements for membership, and privacy policies regarding personal data collection and use. Applicants must sign acknowledging their understanding of the application and authorizing their cooperative to process their enrollment.

Uploaded by

Geraldine Daquipil Tortal
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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COOPERATIVE HEALTH MANAGEMENT FEDERATION

2nd Floor, Unit 208-209 Malakas Suites Bldg., No. 88 Malakas St., Brgy.Pinyahan, Central District, Diliman, Quezon City, Philippines
Tel. Nos.: (02) 283-2321 (02) 931-0387 Email Add: [email protected]

ENROLLMENT APPLICATION FORM (EAF)

PERSONAL INFORMATION DATE OF APPLICATION:


Name:
_____________________________________________________________________________________
(LAST NAME) (FIRST NAME) (MIDDLE NAME)
Address : _______________________________________________________
Tel No: _____________________
Birth Date : _______/_______/________ Age: _________ Sex : ___ M ___ F Civil Status : _______________
Coop / Company : ________________________________ Position: __________________________________
Beneficiary : _____________________________________ Relationship : ______________________________
Plan Type: ______________________________________

MEDICAL INFORMATION

IF ANSWER IS NO DISREGARD QUESTIONS


IF YES, GIVE DETAILS, INCLUDING DATES ON A SEPARTE SHEET IF NEEDED, FOR EACH ILLNESS
1. Do you have any disorder or illness present at birth?

2. Have you had any injury or illness in the past? If yes, kindly specify.

3. Have you received any consultation/ treatment for, any of the following?
A. Loss of consciousness, dizziness, headache, seizure disorder, mental disorder, behavior problem,
paralysis, weakness, mental retardation, strokes?

B. Heart disease, rheumatic fever, palpitation, shortness of breath, chest pain, high/ elevated blood
pressure, heart murmur, etc.?

C. Peripheral Vascular disease s – such as varicose veins, Phlebitis, Aneurysm, Embolism, etc.?

D. Gastric and Peptic Ulcer, gall bladder, liver disease, colitis, chronic diarrhea, fistula, hemorrhoids,
colon or intestinal disorder, hernia, malabsorption syndrome and pancreatitis?

E. Low back pain, bladder or kidney disorder, urinary tract stricture, Syphilis or other venereal disease,
etc.?

F. Diabetes, Gout, thyroid or adrenal disorders and immune system disorder including HIV Acquired
Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC), etc.? If yes, lease specify.

G. Neck and back disorder, Arthritis, fractures, slipped disc, dislocations, joint problems, physical
handicap, etc.?

4. Have you ever needed to be?


A. Hospitalized?

B. Operated on?
5. Do you have any history of anemia or blood abnormalities e.g.Leukemia, increased white blood cell count
or unusual bruising marks on the skin?

6. Are you taking any maintenance medication? If yes, kindly specify.

7. Have you ever received consultation or treatment for?


A. Disease of eyes, ears, nose or throat?

B. Any skin disorder, i.e. skin cancer, Psoriasis, Keratosis, Herpes, etc.?

C. Any history of Cancer/ Tumor?

8. Have you ever been rejected for medical insurance or offered insurance at a higher premium?
I understand that: this medical information must be updated to include any condition or illness, after the date of
submission of the application and prior to COOP HEALTH approval of application; my failure to provide such
information to COOP HEALTH will void the coverage; receipt of membership fees by COOP HEALTH does not
constitute acceptance of the applicant as a member, and finally, COOP HEALTH reserves the right to reject any
application for any reason.-
___________________________________________________________________________________________

I hereby certify that the answers to the medical questionnaire are correct and complete and, to the best of my
knowledge, accurately represent my health. I understand that 1COOP HEALTH may require me to undergo physical
examination or review my medical history. 1COOP HEALTH physicians may discuss with any hospital, healthcare
facility, physicians or other healthcare professional, any and all medical information related to this application. I
understand this information is collected in order to evaluate and process my application, change the benefits, or
to evaluate and process my application, change the benefits or to determine eligibility for the benefits.

With this mind, I apply for 1COOP HEALTH membership and agree to abide by the terms and conditions of the
Contract and 1COOP HEALTH regulations. I understand that unless my application for membership is approved by
1COOP HEALTH, the latter will not be liable for any medical expenses between the time that I sign this application
and the effective date of membership. Any money I may have remitted will be returned if the application is
rejected.

Further, I agree to hold 1COOP HEALTH and/or its directors, officers, and employees free and harmless from any
claim or suit caused by or arising out of non-performance or non-delivery of the services or benefits under this
Program or the denial of a claim for reimbursement, due to the failure of the Group or Company/ principal
member / payor guardian to inform 1COOP HEALTH of my application and/or remit the applicable dues, resulting
in the suspension or inactivation of membership and subsequent denial of coverage benefits.

I also understand that the effectivity and duration of my membership will depend on the date of payment and
remittance of membership fees, as well as submission of required application forms and other documents
required by 1COOP HEALTH.

___________________________________________________________________________________________

I further understand that in order to comply with the obligations of the 1COOP HEALTH, they may outsource or
contract the access to, processing, and use of Personal Data to third parties, such as but not limited to, our
subsidiaries, affiliates, partners, third party service providers. I fully understood and give my consent to have
access to Personal Data for a limited time under reasonable contractual and technical safeguards to limit their use
of such information. 1COOP HEALTH protects Personal Data consistent with its Privacy Policy. As far as I am
concerned, 1COOP HEALTH will be responsible for any breach, committed by these contracted third parties, of
the Policy, of Republic Act No. 10173 or the Data Privacy Act of 2012 (the “Act”) and its Implementing Rules and
Regulations (the “IRRs”) or of other relevant laws.

As an 1COOP HEALTH enrollee, I give my express consent to the collecting and processing of my Personal Data.
This consent shall remain in effect until I withdraw this consent to specific activities done on my behalf, or my
enrollment expires, or my enrollment is terminated.

ACKNOWLEDGEMENT

I have learned and understood from the orientation briefing that our Cooperative provides group medical
and hospitalization program for its members. I acknowledge receipt of this application form needed for my
inclusion in the program, and I assure its completion and submission the soonest possible time.

In this connection, I hereby authorize ___________________________________________________


Cooperative to negotiate and approve in my behalf the terms and conditions of membership in the above-mentioned
program, facilitate processing of my membership, collect and remit my membership fees and fully represent my
interests in all other matters pertaining to my membership.

____________________________________ _______________________________
Authorized / Coop Representative Applicant / Coop Member
(Signature over printed name) (Signature over printed name)

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