Agreement
I hereby apply for the Maxicare Healthcare Program membership and agree that I shall
abide by the provisions of the Membership Agreement and Maxicare Regulations to
which I commit, agree and undertake to be bound by the conditions thereof. I understand
that there shall be no coverage in effect unless my application is approved by Maxicare
and Membership card is issued and hence, that Maxicare will not be liable for any
Medical bills between the time that I sign this application form and the effective
date of my application coverage is approved and membership card/s issued and delivered
to me.
The receipt of the corresponding membership fees by Maxicare does not constitute
acceptance of my application or of my dependents as a Maxicare Healthcare Program
member until the corresponding application has been approved and the membership
card/s has been issued to me or my dependents. In the event that my application
is denied or disapproved for any reason, the membership fees I may have paid or
remitted will be refunded to me by Maxicare.
I hereby agree and undertake as my obligation to obtain from Maxicare the latest
copy of Membership Agreement and to know and understand all the terms, conditions
and provisions enumerated in the said Membership Agreement. Failure to do shall
be construed as a waiver of notice on my part and complete agreement to the new
or amended terms and conditions of the Program.
I hereby agree and undertake as my responsibility, to keep my healthcare program
membership on Active status by paying the corresponding membership fee on or before
the due date. Futhermore, I recognize Maxicare's right to disapprove/deny my application
with no obligation to disclose the reason for such disapproval or denial.