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MAXICARE PLUS DETAILS ON DRAFTING CONFORME LETTER
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CLIENT INFORMATION SHEET
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Complete Name of Signatory:To submit the following for conforme preparation:
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Position of Signatory:1. Master list template of Maxicare
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Signatory Email Address:2. Scanned copy of Company signatory ID, company and Valid ID
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Signatory Contact Number3. BIR 2303
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Complete Company name:
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Complete Company address:
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Effective date (For Group accounts, payment prior to effective date):
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Existing HMO Provider4. PEZA certificate or VAT Exempt certificate, if applicable
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No. of years with the Provider:
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Access to 9 Major hospitals (Option 1 With Access or Option 2 Withour Access):
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Healthway Access: (Yes or No)
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Riders:
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Alternative Standard Dental: (Yes/No)
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Annual Check-Up: (Routine Clinic / Routine Mobile) (Yes/No)
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Grop Life AD&D (Yes/No)
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Daily Hospital Cash Benefit (Yes/No)
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Plan types with rank and classfication:
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EMPLOYEE: Indicate here the ff: (Plan Type / Room & Board / MBL / No. of Enrollees)
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Indicate here the ff: (Plan Type / Room & Board / MBL / No. of Enrollees)
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Indicate here the ff: (Plan Type / Room & Board / MBL / No. of Enrollees)
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DEPENDENT: Indicate here the ff: (Plan Type / Room & Board / MBL / No. of Enrollees)
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Indicate here the ff: (Plan Type / Room & Board / MBL / No. of Enrollees)
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Indicate here the ff: (Plan Type / Room & Board / MBL / No. of Enrollees)
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TOTAL HEADCOUNT
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EMPLOYEE:
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DEPENDENT:
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Mode of payment (Annual/Semi annual/Quarterly): Note: Quarterly is only applicable to Starter Plan account
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Effective date of additional enrollees (Date of Regularization or Date of Hire)
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CLIENT INFO SHEET
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Nature of business:
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Billing address:
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Billing addressee (name of POC reflected in the billing invoice):
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Contact person/s:
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Position:
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Contact number:
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Contact email address:
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Company TIN no.:
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Zip code:
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Billing Set-Up (if per affiliate) (applicable only for the company with affiliate): YES or NO
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ID Card Printing (if per affiliate) (applicable only for the company with affiliate): YES or NO
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Treatment of unused membership fees (Should there be cancelled members, unused membership fees can be treated as: Credit memo or Refund Automatic or Refund by request):
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ALL FIELDS ARE REQUIRED, incomplete data will cause delay of processing.
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