Enrolment form

Agreement

Acknowledgment

By signing this application I declare that I have read, understood and accepted the terms and conditions regarding the effectiveness of the registration, the regulative norm, waiver of preexisting conditions, liability for medical acts, the Law on Protection of Personal Data, the recording of telephone calls, prior information and acceptance of the regulation of services stated in this Enrolment Form.

I authorize MGC to process my personal data, including health related information, when necessary in order to fulfill, monitor and provide the guaranteed benefits, and to be shared between MGC, health professionals and health centers.

In case of being subject to any treatment, I authorize MGC to process the resulting data and to disclose them to the service providers.

These data should be appropriate, relevant and not excessive for the above mentioned purposes. Benefits would not be provided in case of refusal to the treatment or to data disclosure, due to the impossibility of determining aspects covered by the insurance contract.

Above mentioned data will be treated as strictly confidential in abidance of applicable laws and all security measures needed to ensure the confidentiality of the data will be observed.

I have been duly informed that the data will be integrated into an automated file held by MGC, which is responsible for it, and to which I have been ensured the right to access, modify, object, and cancel. In order to exercise that right I can address MGC (Tuset St, 5-11. 08006 Barcelona, Spain).

I am aware that translations included in the contract in any other language other than Catalan and Spanish are, in all cases, of an orientative and informative nature.

Personal information

Address in Spain

Mailing address (address in country of origin)

Delivery address for the identity card of the insured