Professional Documents
Culture Documents
DATE: 2 0 0 1 2 0 2 2
E Z E H S O L O M O N O N Y E K A C H I
SURNAME FIRST NAME OTHER NAMES
DD / MM / YY
Home Address: N O 7 N E W H E A V E N A N N E X A K P A J O
P O R T H A R C O U R T R I V E R S S T A T E
SURNAME:
FIRST NAME:
MIDDLE NAME:
GENDER:
DATE OF BIRTH:
TELEPHONE:
PREFERRED PRIMARY PROVIDER AND PLAN
Please provide correct answer to the questions below for the purpose of quality assurance (mark √ and give appropriate
details):
Question Yes No If yes provide Details
I affirm that the information provided herein in absolutely correct and that any false information or non-disclosure will
invalidate my subscription. I hereby give authorization to Phillips HMO to have access to all my medical record (past and
present). I also hereby acknowledge that I have read and understand and agree to be bound by the terms and conditions
of enrollment with Phillips HMO as well as the benefit package of the plan I am purchasing.