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Please do not provide any personal or confidential health information via this form.
Please note that by submitting this form you are providing permission to Advica Health to contact you.
The undersigned shall be enrolled in the Advica Health program commencing on the effective date set out in the membership agreement above. The listed rates are subject to change upon 30 days’ notice. These rates do not include coverage for or cost of medical treatment, Annual Health Examinations, medications, travel, accommodations or any other overhead costs associated with managing a healthcare issue.
Notwithstanding anything else to the contrary herein, the undersigned or Advica Health may cancel such membership, at any time and for any reason, after the first (1st) anniversary date of the aforementioned effective date upon at least thirty (30) days’ written notice delivered by email to the other party at the Advica Health address first given above or the last address for contact given by the undersigned to Advica Health for its records (as the case may be).
In the event that the undersigned fails to make any payment when due under the Advica Health program, and such payment is not made, in full, within thirty (30) calendar days after written notice is received of such failure, Advica Health shall be entitled, in its sole and absolute discretion, to cancel and terminate the undersigned’s membership and any and all related coverage(s) or treatment(s) under the program, without further notice. As part of this application, and after being accepted as a member, the undersigned acknowledges and agrees that certain information shall be requested and provided, from time to time, concerning his or her personal health, financial and other private matters in connection with the Advica Health program. By signing and delivering this application, the undersigned agrees and consents to Advica Health or its authorized representatives collecting, using, sharing or otherwise disclosing such personal and private information for the purposes of such program and for no other purpose.
Advica Health acts only as a referral agent and navigational assistant for healthcare professionals and related facilities which will provide the treatments and other services to you as contemplated by the membership program (the “Service Providers”). By signing and returning this form, you acknowledge and agree that Advica Health and its employees, agents and authorized distributors are not responsible or liable in any manner for, and will be held harmless by you from any and all claims, demands, losses or damages that may arise from the actions or omissions of the Service Providers as part of the plans, services and programs contemplated by this Membership Application.
Please note that the submission of your details on the membership form does not mean that your membership has been activated. The Advica Health team will process your application and if all fields are appropriately filled out, you will then receive a confirmation email with your membership details and your membership activation date.
The terms and conditions are subject to change at the discretion of Advica Health Inc.