A000B09067-20191122033000

DEPENDENT ENROLLMENT CONFIRMATION FORM [CY: 2019-2020]

EMPLOYEE INFORMATION

Employee Name: MACASERO, NEIL IAN MAYOR

Position/Level: OPERATIONS MANAGER
SBU/Department: NOT PROVIDED
Contact Number: PHILIPPINES / 9166020600
Date of Birth: September 03, 1980
Employee ID: 192593
Hire date: 2017-10-30 00:00:00
Current Civil Status: Single

DEPENDENT INFORMATION
Dependent 1 Fullname: LOIDA BELLA MAYOR MACASERO
Relationship to Employee: Mother
Age: 60.91
Birthday: December 26, 1958
Gender: F Civil Status: M
DEPENDENT ROOM AND BOARD BENEFIT LIMIT QUARTERLY REMARKS/CATEGORY
MEMBERSHIP FEE
Dependent 1 Regular Private PHP 150,000.00 PHP 0.00 Company Paid

I hereby agree to pay the above membership fee/s for my dependent/s through salary deduction within the HMO Policy Year.

Dependents can no longer be cancelled within the policy year once their enrollment is confirmed via Two-Factor Authentication (2FA) and required
supporting documents are submitted for new dependents. Exceptions apply only in the following cases:

Employee resignation;
Death of the dependent;
Coverage of dependent with another HMO provider (subject to approval);
Dependent will work overseas or live abroad

Valid supporting documents must be submitted together with the deletion request.

For new dependents, all required supporting documents must be submitted to complete enrollment

For dependent members enrolled from May 18, 2020 onwards, the maximum limit per illness and the annual pre-existing/dreaded disease limits will be
pro-rated. The computation is:

Total Days Remaining before expiry date / 365 days X Maximum Limit = Limit (or Pre-Existing Condition/ Dreaded Disease Limit).

I hereby authorize Results Manila, Inc. / Results Alaska, Inc. to deduct the above membership fee/s. I understand that failure to accept this form via 2FA will
mean non-completion of my dependents' HMO enrollment process.

03589a7f62976b869f912099e1983ce0 : Sh8xUzg8PGHAY5Bq8sqr35oe8A6
3UMo//AcFgVLQLeuNfwfwmZFP/1uveMLNFO+k
2FA Request ID
Notes:

ActiveLink is only collecting information based on standard underwriting guidelines. Membership acceptance is still determined by your company's HMO
provider.
Final Membership Fees may change based on your dependents' enrollment date or membership effective date with HMO.
Should there be discrepancies in the membership fees stated above versus the formal documentation from the HMO Provider, the HMO Provider
documentation shall prevail.
 ACTIVELINK DATA PRIVACY CONSENT FORM

Strictly Confidential

November 22, 2019

In compliance with the Data Privacy Act of 2012, it is our duty to disclose how we intend to use and process the information we will collect
from you. Furthermore, we seek your consent with regards to the collection and processing of your personal and sensitive information that
will be captured during your registration and enrollment on this website and other ActiveLink services under your HMO program.

It is ActiveLink's top priority to safeguard the user's privacy and maintain the utmost confidentiality in connection with the data or
information that users share or upload through BMB or Benefits Made Better (Website and/or ActiveLink Mobile App), as well as other
ActiveLink services and activities. These include, but are not limited to, HMO Membership, STM Wellness Programs and Projects, Surveys,
APE, Utilization Reports and Analysis, Group Life Insurance, Retirement Program, Pre-Employment Examination, Clinic Management, etc.

By agreeing to this form and proceeding to use this facility, the services on this platform (www.benefitsmadebetter.com,
resultsmanilainc@benefitsmadebetter (dedicated help desk email assigned for your account), inquiries@benefitsmadefbetter.com), and other
ActiveLink services and programs such as installation and use of ActiveLink Mobile Application, you agree (signify consent) to share your
personal and sensitive information and that of your dependents to ActiveLink. The data we collect, as applicable, includes but is not limited
to the following categories of information captured:

HMO Membership
First, Middle and Last Name
Civil Status
Birthdate
Supporting Documents (i.e. Birth Certificate, Marriage Certificate, etc.)
Gender
Employee Number
Email Address
Designation
Contact Details (Mobile/Phone Numbers, Home Address)
APE and Pre-Employment Examination
First, Middle and Last Name
Birthdate
Civil Status
Employee ID
Height, Weight and BMI
Gender
Results and Findings (X-Ray, CBC, Urinalysis, Fecalysis, Physical Exam, Visual Acuity, Pap Smear, ECG, Drug Test
Results, etc.)
Age
Civil Status
GYRT
First, Middle and Last Name
Civil Status
Employee ID
List of Beneficiaries
Gender
Birth Date
Monthly Salary
Sum Insured
BMB Website and Dependents Module (For Employees and Dependents as applicable)
First, Middle and Last Name
Civil Status
Birthdate
Supporting Documents (i.e. Birth Certificate, Marriage Certificate, Affidavits, etc.)
Gender
Principal and Dependents Relationship
Home Address
Mobile Number and Phone Number
Email Address
Signature
Utilization Reports and Analysis
First, Middle and Last Name
Civil Status
Birthdate
ICD Code
Gender
Monitored Cases
 Age
Working and Final Diagnosis Procedure (i.e. X-Ray, Blood Test, Diagnostic Examination, etc.)
STM Wellness Programs and Projects
First, Middle and Last Name
Vital Signs (Blood Pressure, Body Temperature, Respiration rate)
Gender
Employee ID Number
Birthdate
Medical History
Weight and Height
Medical condition
BMI Results (i.e. Body Fat Percentage, Body Fat Mass, Visceral Fat, Muscle Mass, Total Body Water, Bone Mass,
Physique Rating, Basal Metabolic Rate (BMR), Metabolic Age, Body Mass Index, Muscle Quality, Daily Calorie Intake,
Muscle Quality Score, Segmental Muscle Mass, Segmental Body Fat Percentages and Body Type)
Working Diagnosis
Consultation Result
Health is Wealth Monthly Assessment Report
Laboratory Results
Survey
IP Address
Name
Gender
Employee Id
Email Address

By proceeding to register and use this facility, I affirm that:

1. I hereby give consent to ActiveLink to collect, use, store, and process my personal and sensitive information collected for valid and
specified reasons by the BMB website, the ActiveLink Mobile App and other present and succeeding ActiveLink activities or
programs such as, but not limited to, HMO Membership, APE-PEME, GYRT, BMB Registration and Dependents Enrollment,
Utilization Report and Analysis, STM Wellness Program and Projects, Survey, etc.
2. I hereby allow ActiveLink to access HMO utilization data about me and all my enrolled dependents from my HMO provider to
generate utilization reports, validate claims/usage, and design or suggest utilization preventive programs.
3. I, as a principal, have been duly assigned by my dependent to act as their authorized representative, process documents, and attend to
other legal matters of representation necessary for the enrollment of their HMO policy and availment.
4. I am aware that ActiveLink may use third-party platforms to collect responses and other data or information through Wellness
Activities, or programs, or surveys. I believe that these platforms are thoroughly reviewed and aligned with ActiveLink's security
and confidentiality standards. I understand the nature of each third -party platform's functions, to wit:
i. Typeform is used to capture or generate information or data during STM Wellness Activities. (To know more about
TypeForm securing data or information, please visit: https://admin.typeform.com/to/dwk6gt).
ii. Survey Monkey is used to generate members' surveys for the improvement of service delivery to clients. (To know more
about Survey monkey's policy on protecting data or information, please visit:
https://www.surveymonkey.com/mp/legal/privacy-policy/)
iii. Mail-Chimp is used to deliver announcements via electronic mail to clients or members. (To know more about Survey
monkey's policy on protecting data or information, please visit: https://mailchimp.com/legal/privacy/)
5. I hereby give consent to ActiveLink to share my details with my Company HR, Company Clinic and other authorized personnel
involved in my HMO program, to aid in the creation of initiatives for improving my health and wellness, such as activities and
programs, improved utilization management, company clinic database to improve clinic services, reviews of HMO pricing and
availment claims, etc.
6. I hereby allow ActiveLink to safeguard my data beyond the end of its engagement with my company as provided by any prior
agreements, or to otherwise retain my data for a period not exceeding 5 years. Permission to use my personal information, and that
of my dependents, will not expire during the aforementioned period.
7. I hereby agree that ActiveLink's collection of data is not limited to my initial disclosure but extends to all subsequent entries or
updating of informationas well as prior information shared.
8. As per the Data Privacy Act of 2012 and its Implementing Rules and Regulations, I hereby agree that I am aware of my rights as a
data subject, which encompass the right to be informed, to object, to access, to correct, to ensure erasure or blocking, and to file a
complaint as necessary.
9. I agree that my data shall be stored and kept within the ActiveLink cloud server facility for the aforementioned period from the onset
of data collection or until prior valid request by the company. (To know more about how ActiveLink protects your data or
information, please see ActiveLink's Privacy Policy: https://www.benefitsmadebetter.com/page.php?page=privacy-policy)
10. I understand that my participation is voluntary and that I am free to withdraw any time and without my medical care or legal rights
being affected. You can exercise this right upon discovery and substantial proof of the following:

i. Your personal data is incomplete, outdated, false, or unlawfully obtained.

ii. ii. It is being used for purposes you did not authorize.
iii. The data is no longer necessary for the purposes for which they were collected.
iv. You decided to withdraw consent, or you object to its processing and there is no overriding legal ground for its processing.
v. The data concerns information prejudicial to the data subject — unless justified by freedom of speech, of expression, or of
the press; or otherwise authorized (by court of law)
vi. The processing is unlawful.
 vii. The personal information controller, or the personal information processor, violated your rights as data subject.
Should the data subject opt out of the list, any identifiable data shall be removed from file:

i. All identifiable data shall be removed from the file. However, any results or data without personal identifiable item shall be
preserved for research, study and reporting purposes.
ii. That all data linked to the data subject may not be recovered anymore given the delisting and deletion of any personal
identifiable data.

11. By signing below, or by digitally proceeding in providing consent via 2FA facility or similar tool within the website or mobile
application, I signify that I have read and understood all of the above provisions.

You, as a participant, have the right to access, modify, and cancel the processing of your personal data at all times upon informing
ActiveLink. To do so, please contact our data privacy support team at dataprivacy@activelinkbenefits.com.

Very truly yours,

03589a7f62976b869f912099e1983ce0 : Sh8xUzg8PGHAY5Bq8sqr35oe8
A63UMo//AcFgVLQLeuNfwfwmZFP/1uveMLNFO+k
2FA Confirmation Request ID
{space}

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

LOIDA BELLA MAYOR MACASERO

 INTELLICARE DATA PRIVACY CONSENT FORM

Strictly Confidential

November 22, 2019

I consent to Results Manila, Inc. and/or ActiveLink's collection, processing and disclosure of my and/or
my dependent/s' personal information, including my and/or my dependent/s' sensitive personal
information, such as age, residence, medical records and past medical history, etc. including but not
limited to, results of medical examinations, diagnosis, abstracts, treatments, and utilizations (collectively
referred herein as \"Information\"), for purposes of Results Manila, Inc.'s fulfillment of its obligations as
my employer under the law, which may include, at its own discretion, providing me with health care
benefits.

I understand that all Information furnished to, and/or collected by Results Manila, Inc. and/or ActiveLink
shall be used and processed by all personnel, subcontractors, and medical facilities connected with
Results Manila, Inc. including, but not limited to, its doctors, nurses, and brokers/consultants. I am also
aware that the Information collected from me shall be stored by Results Manila, Inc. and/or ActiveLink
for a period of 5 years, and I may access or correct said Information. In case of any inquiries or dispute in
relation to my Information, I may contact ActiveLink at resultsmanilainc@benefitsmadebetter.com or
lodge my complaint at the National Privacy Commission.

I hereby hold Results Manila, Inc. and/or ActiveLink and its officers and directors free and harmless from
all claims, suits, charges, damages, or liabilities arising from or connected with the collection, processing,
and release or disclosure of my and/or my dependent/s' Information, including any claims, suits, charges,
damages, or liabilities under the Data Privacy Law of 2012 and its Implementing Rules and Regulations.

03589a7f62976b869f912099e1983ce0 : Sh
8xUzg8PGHAY5Bq8sqr35oe8A63UMo//
AcFgVLQLeuNfwfwmZFP/1uveMLNFO
+k
2FA Confirmation Request ID
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

LOIDA BELLA MAYOR MACASERO

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