Maxicare Customer Information Form Instructions and Details

To submit this form, please ensure all fields are filled out correctly and all required documents are attached. Email your form to cifteam@maxicare.com.ph or submit it via fax to 582-1900 or 798-7777. You can also send your physical documents to Maxicare Tower, 203 Salcedo Street, Legaspi Village, Makati City. Our advice is to keep copies of all submitted documents for your records.

Ensure to submit your form before your Maxicare contract expires. Renewal dates and other important deadlines are provided by Maxicare based on individual contracts.

The purpose of this form is to gather essential customer information required for Maxicare healthcare services. By providing accurate details, members ensure a smooth processing of their healthcare benefits and services. Additionally, this form outlines the terms and conditions governing the Maxicare Reimbursement Card to keep members informed.

• 1. Cardholder's Name: Provide your full name, including last, first, and middle name.
• 2. Maxicare Card No.: Enter your Maxicare Card number.
• 3. T.I.N.: Provide your Tax Identification Number.
• 4. SSS No.: Enter your Social Security System number.
• 5. Mobile No.: Provide your mobile number or Unified ID number.
• 6. Passport No. / ACR No.: For foreign individuals, provide your Passport or Alien Certificate of Registration number.
• 7. Home Phone Number: Enter your home phone number and check the box if it matches your mobile number.
• 8. Date of Birth: Provide your date of birth in MM/DD/YYYY format.
• 9. Place of Birth: Enter the city, municipality, province, and zip code of your birth place.
• 10. Mother's Maiden Name: Provide your mother's full maiden name.
• 11. Present Address: Enter your current residence address with full details.
• 12. E-mail Address: Provide your primary email address.
• 13. Permanent Address: Enter your permanent residence address and check the box if it matches your present address.
• 14. Civil Status: Select your civil status from the given options.
• 15. Citizenship: Provide your citizenship status.
• 16. Gender: Select your gender.
• 17. Educational Attainment: Specify your highest educational attainment.
• 18. Name of Business/Employer/School: Provide the name of your business, employer, or school.
• 19. Nature of Business/Work: Describe the nature of your business or work.
• 20. Occupation: Enter your occupation or position.
• 21. Source of Fund: Select your source of fund from the given options.
• 22. Valid ID: Select and provide a photocopy of a valid ID as specified.
• 23. Member's Signature: Sign and date the form as an acknowledgment of the terms and conditions.

Failing to submit this form can result in the denial of your healthcare benefits and services. It's crucial to complete and submit the form within the specified timeframe.

• Denial of Services: Maxicare may deny healthcare services if the documentation is incomplete.
• Loss of Coverage: You risk losing your healthcare coverage if the form is not submitted.
• Delayed Processing: Your healthcare claims and reimbursements may be delayed.
• Invalid Information: Incorrect or missing information can lead to additional processing time.
• Non-compliance: Non-compliance with form submission requirements can affect your membership status.

• 1. New Membership Enrollment: Use this form to enroll as a new Maxicare member.
• 2. Update Member Information: Update your personal details such as address, contact information, and civil status.
• 3. Healthcare Reimbursement Claims: Submit this form for healthcare reimbursement claims.
• 4. Card Replacement: Use this form to request a replacement for a lost or stolen card.
• 5. Renewal of Maxicare Plan: Complete this form to renew your existing Maxicare healthcare plan.