PLEASE WAIT WHILE LOADING...
Login as
Close
Member (Member Gateway)
Doctor/Clinic/Hospital (PAMS)
HR (HR Gateway)
Agents (Agents Gateway)
Brokers (Brokers Gateway)
Employee (Employee Gateway)
Menu
Close
Prepaid Online Registration
Health and Wellness
Lifestyle Partners
Availment and Reimbursement Procedures
Primary Care Centers and Helpdesks
Latest News and Events
FAQs
Glossary
Contact Us
Menu
Healthcare Program for Me and My Family
Close
Product Offerings
Availment and Reimbursement Procedure
Online Payment
Healthcare Program for My Organization
Close
For Small Medium Enterprises (SMEs)
Product Offering
Availment and Reimbursement Procedure
Health and Wellness
Online Payment
For Corporate
Product Offering
Availment and Reimbursement Procedure
Health and Wellness
Online Payment
Intermediary Partners
Close
Agents
Why become a Maxicare Agent?
How to become a Maxicare Agent
Apply Online
Brokers
Why partner with us?
How to become a partner?
Apply Online
Providers
Close
Be Affiliated with Us
Latest News & Announcements
Doctor/Dentist Affiliation Request
Clinic/Hospital Affiliation Request
Why Choose Maxicare
Close
Who We Are
Our Team
Our Milestones
Careers
Providers
Be Affiliated with Us
News & Announcements
Log In
Home
Be Affiliated with Us
Provider Affiliation Request Form
Provider Affiliation Request Form
Incomplete request form shall not be processed
To be accomplished by the Requesting Party
Date of request*
Provider Name*:
Provider Address
No. of Bldg./House/Lot*
Floor
Building
Street
Region*
- Select Region -
NCR
CAR
Region I
Region II
Region III
Region IV - A
Region IV - B
Region V
Region VI
Region VII
Region VIII
Region IX
Region X
Region XI
Region XII
Region XIII
ARMM
Province*
- Select Province -
City/Municipality*
- Select City/Municipality -
Contact Number
Mobile
Fax
Telephone Number
Email Address
Branch
+ Add Branch
List of requirements (please submit certified true copy of the following)
Clinic profile with location map
Laboratory Prices
List of Physicians
DOH License
Sanitary permit
Waste disposal scheme permit
Philhealth
License to operate
VAT Registration
Letter of intent
