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HMO Application - Dependent

This document is an HMO dependent registration/withdrawal form. It collects information about an employee such as their name, employee number, birth date, civil status, and plant/department. It then lists the employee's dependents including their name, birth date, and relationship to the employee. The employee agrees that the information provided is true and authorizes the sharing of medical information. They also agree to pay a monthly fee per dependent. Supporting documents such as birth certificates or marriage contracts must be provided for new dependents. The form also allows the employee to withdraw their dependents from coverage and acknowledges the dependent will no longer be covered after withdrawal.

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Beybey
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501 views

HMO Application - Dependent

This document is an HMO dependent registration/withdrawal form. It collects information about an employee such as their name, employee number, birth date, civil status, and plant/department. It then lists the employee's dependents including their name, birth date, and relationship to the employee. The employee agrees that the information provided is true and authorizes the sharing of medical information. They also agree to pay a monthly fee per dependent. Supporting documents such as birth certificates or marriage contracts must be provided for new dependents. The form also allows the employee to withdraw their dependents from coverage and acknowledges the dependent will no longer be covered after withdrawal.

Uploaded by

Beybey
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLS, PDF, TXT or read online on Scribd
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HMO DEPENDENT/s REGISTRATION / WITHDRAWAL FORM

DEPENDENT/s REGISTRATION DEPENDENT/s MEMBERSHIP WITHDRAWAL

EMPLOYEE NAME: EMPLOYEE NO.: BIRTH DATE:

CIVIL STATUS: DATE APPLIED: PLANT: DEPARTMENT:

NAME OF DEPENDENT
BIRTH DATE RELATIONSHIP
(Surname, Given Name, Middle Name)

1.

2.

3.

4.

5.

6.

7.
DEPENDENT/s REGISTRATION :
I understand that this insurance will be issued based on the above statements which I represent are true
and complete to the best of my knowledge. I authorize any physician, hospital, clinic, or any medically- related
facility to furnish Maxicare information leading to my dependent's medical history and physician condition.
Furthermore, only those dependents registered above shall be entitled to Cocolife benefits.
I hereby agree that if there be any misinterpretation in the above statements, Cocolife shall have the right
to reject and declare such insurance null and void.

I further authorize the Company to deduct P_____ / dependent / month from my salary.

SUPPORTING DOCUMENTS TO BE SUBMITTED( for new/additional dependents ):


SINGLE PARENT NOT SMC EMPLOYED BIRT CERTIFICATE OF EMPLOYEE

BROTHER / IF BOTH PARENTS ARE DECEASED, ORPHANED SIBLINGS BELOW21 YEARS OLD AFFIDAVIT OF SUPPORT FOR PARENTS

SISTER AND TOTALLY DEPENDENT ON THE EMPLOYEE FINANCIALLY.

MARRIED / SPOUSE / LEGITIMATE AND NOT SMC EMPLOYED MARRIAGE CONTRACT

WIDOWED / CHILDREN LEGITIMATE, LEGITIMATED OR LEGALLY ADOPTED

LEGALLY UNMARRIED AND UNEMPLOYED BELOW 21 YEARS OLD AND TOTALLY BIRTH CERTIFICATE/S OR LEGAL ADOPTION

SEPERATED DEPENDENT ON EMPLOYEE FINANCIALLY. PAPERS OF CHILDREN.

DEPENDENT/s MEMBERSHIP WITHDRAWAL :


I understand that withdrawal of my dependent/s from HMO is a voluntary act and I agree to the ff.:
*My dependent/s is/are no longer covered by SMCGP's Health Plan for Dependents effective at
the date of withdrawal.
*I cannot enrol them anytime during the policy period.
*I take full responsibility for my dependent/s medical needs including hospitalization.
EMPLOYEE SIGNATURE: DATE:

NOTED BY: DATE:

(Immediate Superior)
NOTED BY: DATE:

(HR Head)

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