Hospital Affiliation Form / 2 - Premier Healthcare Provider in the Philippines | Maxicare Corporation

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About Us Overview navigate_nextProvidersnavigate_nextHospital / Clinic Affiliation Form

Be part of the widest HMO network in the country

Join us as we improve healthcare for Filipinos all around the country

20 minutes to complete

Provider name (Fields with an asterisk * are required)

Provider name*

This field is required

Provider address (Fields with an asterisk * are required)

Number of building / house / lot*

This field is required

Floor

This field is required

Building

This field is required

Street

This field is required

Region*

This field is required

Province*

This field is required

City or Municipality*

This field is required

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Provider contact details (Fields with an asterisk * are required)

Mobile number*

+63

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Telephone number

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Email address*

This field is required

Branch*

This field is required

Add branch

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Kindly submit a certified true copy of the list below

1. Clinic profile with location map

5.7 MB

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filename

Only JPEG, and PDF file formats with a maximum file size of 10MB

2. Laboratory Prices

5.7 MB

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filename

Only JPEG, and PDF file formats with a maximum file size of 10MB

3. List of physicians

5.7 MB

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filename

Only JPEG, and PDF file formats with a maximum file size of 10MB

4. DOH License

5.7 MB

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filename

Only JPEG, and PDF file formats with a maximum file size of 10MB

5. Sanitary permit

5.7 MB

Drag & drop or browse your files

filename

Only JPEG, and PDF file formats with a maximum file size of 10MB

6. Waste disposal scheme permit

5.7 MB

Drag & drop or browse your files

filename

Only JPEG, and PDF file formats with a maximum file size of 10MB

7. PhilHealth

5.7 MB

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filename

Only JPEG, and PDF file formats with a maximum file size of 10MB

8. License to operate

5.7 MB

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filename

Only JPEG, and PDF file formats with a maximum file size of 10MB

9. VAT Registration

5.7 MB

Drag & drop or browse your files

filename

Only JPEG, and PDF file formats with a maximum file size of 10MB

10. Letter of intent

5.7 MB

Drag & drop or browse your files

filename

Only JPEG, and PDF file formats with a maximum file size of 10MB

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