TORT TOSI DEPENDENT ENROLLMENT CONFIRMATION FORM (CY: 20172018] [EMPLOYEE INFORMATION. Employee Name: QUIAMBAO, ALYSSA MARIE PositLavet: SUPPORT SERVICES ‘SBUIDeperiment’ NOT PROVIDED Contact Number: 9955362548 S056952548 Dateof Birth: November 04, 1989 Employee 0: 256242 Curent cit Status: Sige DEPENDENT INFORMATION Dependent + Fulrame: AL PLIQUIANBAO elotonshipto Employee Father ‘es: 5210 ‘ienday. June 14 1965 ‘Gender W Custos Dependents Fathame MAMA DRNGRNAN GUAMBAO Relotonstipto Employee Mothor Age 4880 iendoy: January 15,1960 Gender ct tae ‘DEPENDENT ROOM AND. Dependent Sem eva a 000.0 Tonpany Pa Dependent Serna BH a 00.00 omgany Psi + Dependents can mo engr be cael nn the ply year once the enon conrad eco the foto canons: Employee reelgnater, Dea te epandort, Cverage of Jepee wh enter HMO grove! oppor); Dependert wl wo oversea ore ‘Soond Vaid sopping Socomarts ust be subi tgehr wah he cron reset «+ Kaptin soy ctertng lomaon based on nancard Underuingguees, Mane aowpanc si éteminey your camsan/'s HMO row s70099ek749567 tedb7emdsdaeeb023: BATOZAPKABGDTOSnzsleNea "YoWEXxDEXOghTOOXAGLZGnIBELy2n0EA 95,026 THA RequestACTIVELINK DATA PRIVACY CONSENT FORM ‘Sts Confidential August 23,2017 ‘ACTIVELINK, “7 Floor Elecra House Building, {S117 Esteban Steet, Legaspi Village, Makati City ATTENTION: ALYSSA MARIE QUIAMBAO Support Services ‘THRU: ‘Manalife- Philippines SUBJECT: MEMBER CONFORME 2 eect att te this facility (wwwbenefsmadebetercom, manulife@benefismadebenercom, BiisesGheneftsmadetiercom) Tages (signify consent) to share my personal information and that of my dependents to Aetheln Dasa tobe collected are the following ~ fall name of your dependents, emal address (employers and dependents) rod ober conte eon {rob or fandine phone number, email adres, etc) du of birth, evil ts, relalonhip to the principal member ce colores, parting documents to exablish the reaonship to the principal member or employee, and oer rran dai within the Depends Enrollment modal, . orpany fac § years. My permission to se my persona information, and that of my dependets, wll ot expire during te afremeeioned beri, and hereby ares that ActiveLink's colletion of data isnot limiedto my intl disclosure, bu etcndst all becuse en oe ‘Updating of information, aswell as pror information shared, All main data fle hall be stored eleceoniclly at Acdvelinks eee ncn (hrough Third Party Data Server Provider inthe US.) Very truly yours, '370909%9eb7485671edy7e94Sdaee8923 : BOTOZAPKsBgDTDShzeleNaq ¥+WEX«D¢XOghiT OoXAghZGnIB6ely2nOE/L9SIO2IG FA Confiemation Request 1D For Dependent of Legal Age: By affixing your signature below, you freely, Knowingly and voluntarily given your ‘consent as described in this document. Name Signature “xr ___ AL PILI QUIAMBAO ( MA. MIA DANGANAN QUIAMBAOMAXICARE DATA PRIVACY CONSENT FORM. ‘Stritly Confidential ‘August 23, 2017 ‘MAXICARE HEALTHCARE CORPORATION Maxicare Tower 203 Salcedo Street, Legaspi Village Makati City ATTENTION: ALLYSSA MARIE QUIAMBAO. Support Services THRU: Manulife - Philippines SUBJECT: MEMBER CONFORME Gentlemen: Tn reference to my and/or my dependenvs! healtheare plan procured by the Company, I hereby certify that T and my dependents have read and understood the Summary of Coverage and Renefits ofthe Service Agreement executed by Maxicare Healtheare Corporation ("Maxicare") and the Company including all procedures, benefits, exclusions, li tions and conditions contained therein, and agree to be bound thereby. Furthermore, by availing the services of Maxicare, I and my dependent acosge we agro abe by l te mebeship teas an conditions pblised ve Maree web /maxicare,phimember-erms. ‘In executing this document and in affixing my signature hereto, I confirm that: “agree and understand that in the course of providing service/s to me of my dependents, Maxicare shall engage the services of, and/or interact with, other third parties, such as, but not limited to its parent company, affiliated companies, subsidiaries, financial advisors, affiliated third parties or independenvnon-affiliated third parties and service providers, whether local or foreign (collectively referred to as "Representatives"). ‘Land my dependent/s have fteely, knowingly and voluntarily given my consent for Maxicare and its Representatives to: Obtain, collect, examine, process, and store copies of my and/or my dependents personal information, including sensitive personal information, privileged information, medical records or any other information, relative to my (and/or my dependents’ hospitalization, consultation, treatment or any medical advice in ‘connection with the benefivelaim availed under the Agreement as may be deemed necessary by Maxicare. [Except as otherwise stated hereon, any information obtained relative to the authority herein given shall be ssricly confidential. The extent of the collection and processing shall be necessary and incidental to the performance ofthe services contemplated in the Agreement, 1 Disclose such information to the Company, is representatives, agents and brokers, Meicare and its Representatives, including the service providers which will perform the services contemplated in the _Agrecment, or any legate busines purpose as Macre may deem appropri, isdn tnt ited to outsourced processing of Maxicare nsctons, poling or historia statistical analyse, providing advice or information which Maxicare and its Representatives believe may be of interest to me or the Company, to effectively administer or manage my account, enhance customer services, or to communicate with me or the Company for ny purpose. Processing is hereby understood to include any operation or any set of operations performed upon personal information including, but not limited to, the collection, recording, organization, stofage, updating or modification, revieval, consultation, wse, consolidation, blocking, erasure or desruction of data. Prbcedsing would include both ‘anal end automated handling of personal information and storage and data transfers using various means nchuding ‘but not limited to physical methods as well as electronic va information and communications systems employed by Maxicare and its Representatives.3, Thave been duly authorized by my dependents wo sign and execute any and all documents and make representations {or and in his/their behalf as if the same were personally done by himvthem, 4, Thereby warrant that we understand our rights and obligations pursuant to the Data Privacy Act and its implementing. rules and regulations. I and my dependents understand that we retain the right to be informed, to object, access, complain, and rectify, to request for fillering of certain information, and to the corresponding damages in case of violation of our rights within the corresponding limitations as set forth inthe pertinent laws. 5. 1 and my dependents hereby represent that, inorder to provide the services contemplated in the Agreement, the authorities herein provided shall be valid and existing during the term of the Agreement, inchuding any extensions ‘hereof, and until necessary forthe establishment, exercise or defense of any claims arising from the said Agreement, 6. Tand my dependents hereby agree to hold Maxicare and its Representatives free and harmless from and against any and al suits or claims, ations, or proceedings, damages, costs and expenses, including attorney's fees, which may be filed, charged or adjudged against Maxicare or any of its directors, stockholders, officers, employees, agents, of Representatives in connection with or arising from the use, provessing and disclosure by Maxicare or its Representatives of the aforementioned information pursuant to Maxicare’s relimce on my and my dependents representation and warranty that Maxicare, the Company, and their representatives have the authority to examine, use, process, sore, share, or disclose, asthe ease may be, said information forthe above-mentioned purposes. 7. Maxicare reserves the right to amend the Membership Terms and Conditions at any time without nged of prior notice or approval, and any queries related thereto may be addressed to compliance@maxicare.com ph. ‘Very truly yours, '3709099eb7485671edb7¢945daee8923 : BQTOZaPKsBgD7DShz cleNagV+ WEXxDEXOghTOOX AgbZGnIB6tIy2nOR/I.95J02I6 ‘FA Confirmation Request 1D For Dependent of Legal Age: By affixing your signature below, you freely, knowingly and voluntarily given your ‘consent as described in this document. Name Maxicare Mem! No. si ALPILI QUIAMBAO. _ COBO) ~ 12023205480! Who MA.MIA DANGANANQUIAMBAG —__POABDD -MODSINSIQOS, 777 Gace env