Annual and Executive Check-Up Request Form
Form Template Control: Wellness, Medical Resource & Research/May 31, 2019/FO-WMR-0.005/Rev.01
WELCOME TO THE NEW ANNUAL AND EXECUTIVE CHECK-UP REQUEST FORM
Upon filling out and submitting this form, you and your dependent, freely and voluntarily give your consent for Maxicare and its representative to obtain, collect, examine, process and store your personal information including sensitive and privileged information. You and your dependent also warrant and authorize to disclose the information to the service providers which will perform the services for any legitimate business purpose as Maxicare may deem appropriate, including but not limited to outsourced processing of Maxicare transactions, profiling or historical statistical analysis, providing advise and information which Maxicare and its representative believe may be of interest to you or to communicate for any purpose.
1. This form is intended to all Individual and Family Account.
2. For rescheduling request, members will directly coordinate with the provider.
3. Kindly fill-out all required fields with asterisks (*)
4. Please indicate the Email Address of the member on the required portion below.
Alternative Email Address
This is intended for other email address aside from the email address indicated above.
Double check all information before proceeding and submitting the form. Any change in details, a new request must be submitted.
Page 1 of 4
Never submit passwords through Google Forms.
This form was created inside of Equicom Group.