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1CoopHealth HMO Enrollment Form You must be an HPPCOOP Member to be able to enroll in one of the HMO Plans below. Privacy Statement Name to Appear on HMO Card
Lastname:* Firstname:* Middlename:* Email:* Gender:* Male Female Birth Date:*

TIN Number (123-456-789):* SSS Number (12-3456789-0):* Phone:* Permanent Address:* Protection Code:* Please enter text shown in the image below. captcha code

If approved, I wish to enroll the above person to the following Honorary Member programs: Select Payment Option: One-Time 3 Months To Pay (1% add-on interest per month) Ward Plan (P4,350.00/year for 18-65 years old, x2 for 66-70 years old, x3 for 71-75 years old) Semi-Private (P10,450.00/year for 18-65 years old, x2 for 66-70 years old, x3 for 71-75 years old) Semi-Private 6MH (P11,710.00/year for 18-65 years old, x2 for 66-70 years old, x3 for 71-75 years old) Private (P17,420.00/year for 18-65 years old, x2 for 66-70 years old, x3 for 71-75 years old ) Private 6MH (P19,516.00/year for 18-65 years old, x2 for 66-70 years old, x3 for 71-75 years old ) 1CoopHealth HMO Plan (Choose One) Hospital Income Benefit:** With Access to 6 Major Hospitals* Without Access to 6 Major Hospitals* *6 Major Hospitals - Medical City, Makati Med Outpatient Services, St. Luke's QC, St. Luke's BGC, Cardinal Santos, Asian Hospital Your Coop ID:* *Not yet a member? Click here to apply. Sample computation for 3 Months To Pay for Ward Plan (P4,350.00):
Monthly Interest = P4,350.00 / 3 months x 1% = P43.50
Total Monthly Amortization = P4,350.00/3 + P43.50 = P1,493.50 (for 3 months)

Registered User
CoopID: 
Name:   
Email:

** Please click here for more info on HIB and HMO Plans.