2021 BDO STAFF’S FIRST DEPENDENT HMO ENROLLMENT FORM

FULLY SUBSIDIZED / FREE-OF-CHARGE

This enrollment form is for the BDO Staff’s FIRST DEPENDENT ONLY.
THE HMO MEMBERSHIP FEE FOR THE FIRST DEPENDENT IS FULLY SUBSIDIZED BY THE BANK BASED ON THE BDO & BDOEA CBA.

EMPLOYEE INFORMATION (PLEASE PRINT PROPERLY)

Last Name First Name Middle Name Employee No. as indicated in the
BDO Employee ID.:

Birth Date (MM/DD/YY) Designation/Position: AGE: Date Hired: (MM/DD/YY)

Department / Branch /Complete Address: Civil Status: Married Widow/er

Single Legally Separated (attach copy of court
decision)
Contact No. of Employee:
Office Tel. No.: Residence Tel. No.: Mobile No.: Personal E -Mail Address:
DEPENDENT’S DATA

NAME (Please print legibly) Civil Date of Relationship

Status Gender Birth (Please check appropriate box)
Last Name First Name MI
Spouse Child Parent
Sibling (Brother & Sister)

OPTIONAL ADD-ON RIDER FOR NON- PHILHEALTH MEMBERS

THE HMO WILL COVER THE PHIL HEALTH SHARE IN CASE OF HOSPITALIZATION OF THE MEMBER ONLY IF THE PHIL HEALTH PREMIUM IS PAID.
Please check box below if your dependent is a non-Phil Health member.
My dependent is a Non-Phil Health member. I hereby agree to settle the amount of P3,024.00 as premium payment (to cover for 12 months) for the Phil Health portion of the hospitalization cost in case of my dependent’s
confinement. It is understood that nonpayment of said amount would mean, I will settle the actual Phil Health portion.
Payment shall be made thru a deposit to VALUE CARE HEALTH SYSTEMS, INC., BDO Account No. 343-000-4076.
________________________________________
Employee’s Signature Over Printed Name
Note: Please send a copy of the machine validated deposit slip together with the enrollment form to BDOEA MEDICAL CONCIERGE OR BDOEA OFFICE.
Please ensure that you write the full name of the member on the deposit slip.

FULL HMO HOSPITAL-BASED PLAN

(Effective Jan. 1 up to Dec. 31, 2021)
With Access in VRP MEDICAL CENTER, CSMC, SLMC GC & QC and all other Valucare accredited Hospitals/Clinics except
The Medical City, Makati Medical Center, Asian Hospital & Medical Center, TMC Satellite Clinics, FortMed Clinics and Healthway Clinics.

SALIENT BENEFITS:OUT-PATIENT COVERAGE; IN-PATIENT COVERAGE; EMERGENCY (ER) COVERAGE; ANNUAL PHYSICAL EXAM (APE); DENTAL COVERAGE

PRE-EXISTING CONDITIONS (PEC) IS COVERED UP TO PHP155K/ILLNESS/INJURY/MEMBER/YEAR FOR THOSE ENROLLED EFFECTIVE JANUARY 2021.

For employees who are newly regularized/newly married and with a newborn dependent, dependent’s coverage for Pre-existing conditions shall be pro-rated based
on the month of enrollment.

ELIGIBLE DEPENDENTS – Persons designated by a Principal for membership under the BDO Dependents’ Healthcare program.
A) Married Principal – Hierarchy: 1st Priority – Spouse not more than sixty-five y/o (65); 2nd Priority – Legitimate, legally adopted, or legitimized child who is unmarried,
unemployed, wholly financially dependent on the member, at least fifteen (15) days old and not more than twenty-one y/o (21).
B) Unmarried Principal - Hierarchy: 1st Priority – Biological or legally adopted child who is unmarried, unemployed, at least fifteen (15) days old and
not more than twenty-one y/o (21); 2nd Priority - Parent not more than sixty-five y/o (65); 3rd Priority - Brothers or Sisters at least (15) days old and
not more than twenty-one y/o (21); only if wholly financially dependent on the member.
IMPORTANT:
• Enrollment of brothers, sisters and children must be in order of age starting with the eldest to youngest.
• Documentation is required to validate the HIERARCHY OF ENROLLMENT. Those skipping the hierarchy due to membership of dependents with
other HMOs must submit a photocopy of the dependent’s current HMO ID card. The same must be attached to this enrollment form. Otherwise,
enrollment of dependent will not be processed.
• For Single Parents, please submit the birth certificate of child.
____________________________________________________________________________________________________________
I hereby enroll my FIRST QUALIFIED DEPENDENT under the FULL HMO HOSPITAL-BASED PLAN. I agree to the automatic renewal of my dependent’s HMO
membership thereafter. I also agree to the benefits and the terms and conditions of the HMO-BDO/BDOEA Healthcare Service Agreement. (HSA). Further, I
authorize Health, Well-Being & Resources Unlimited (HWRU) to use the information stated above to process my dependent’s HMO membership and administer
the benefits as stated in the HSA.

_________________________________
Employee’s Signature Over Printed Name
________________________________________________________________________________________________________________

ENROLLMENT GUIDELINES:
1. For employees with qualified dependents, enrollment starts on January 1, 2021 to February 28, 2021, every month thereafter for newly regularized employees.
2. Enrollment of dependents of newly regularized employees must be within sixty (60) days from the date of regularization / assumption of duty.
3. Only new born dependent & spouse of newly married employees will be allowed as additional dependents. Enrollment must be within 60 days from date of birth or date of marriage.
4. Once enrolled, cancellation of dependent’s enrollment shall not be allowed within the contract period.
5. Please read the 2021 HMO IMPLEMENTING GUIDELINES.
6. You may send your duly filled in forms or call for your inquiries or LOA assistance to HWRU:

ROSALYN “ KEN” CANEZA PATRICIA CORPUZ MARGE ROSALES

Operations Manager / HWRU Membership Data Officer /HWRU Membership Processor /HWRU
Tel. No. (02) 8846-6833 Tel. No. (02) 8817-6950 Tel. No. (02 ) 8845-0861
Mobile Nos. 0917-849-4259 Mobile Nos. 0917-841-0848 Mobile Nos. 0917-848-7214
Fax No. (02) 8892-4566 Fax No. (02)8892-0162 Fax No. (02) 8892-0162
rosalyn.caneza@hwru.org patricia.corpuz@hwru.org 1818medcon@hwru.org

ATTENTION : MS. BADETTE OLIVAR

BDOEA Office Staff
BDOEA-ALU OFFICE
Ground Floor, EBC Bldg., Ortigas Avenue corner Roosevelt Avenue
Greenhills, San Juan, Metro Manila
Tel. No. (02) 8840-7000 local 32914/32915
Direct Line : 8840-7803 Fax No.: 8840-7805

NOTE: HWRU is BDOEAs HMO Plan Administrator and the adjunct office of BDOEA, primarily to serve the healthcare needs of the members.
1818 Medical Concierge is the BDOEA MEDICAL CONCIERGE’s omni-channel communications administrator. It is a 24/7 medical
concierge servicing the day to day medical assistance requirements of the BDOEA members and dependents, nationwide.