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Discount Medical Plan Application




Upon submission of this secured form, Aegis Administrative Services Inc. will charge your credit card for the Tricare-Healthpack Discount program.

This Program Is NOT INSURANCE.

Please complete the form fully to insure the proper charge to your account.

Thank you for using our online services

* - Required Fields

1. Select your payment plan

This program contains a Prescription Drug, Aetna Dental Access, Vision, Hearing, Health Hotline and 24hr. Nurse Hotline Discount Programs.


Monthly Annual Rate

 19.95 Monthly

Annual Rate w/ 10% Discount

 215.46 Annual

2. Customer billing information
First Name:*  
Last Name:*  
Company Name:  
Date of Birth:*  
Sex:*  
Telephone:*  
Street Address:*  
City:*  
State:*  
Zip:*  
Billing Address
(if different):		  
City:  
State:  
Zip:  
Email:*  
   
3. Credit Card Information  
Accepted Cards: Visa, MasterCard, American Express, Discover
Card Number:* (enter number without spaces)
Expiration Date:* (MMYY)
Card Code:*  
   
4. Complete if spouse and/or children are included.
Spouse's Name: Date of Birth
Child's Name: Date of Birth
Child's Name: Date of Birth
Child's Name: Date of Birth
Child's Name: Date of Birth
Child's Name: Date of Birth
Child's Name: Date of Birth
   
5. Signatures  
Applicants
Signature:*		 Typing your signature and confirming your signature authorizes release of your information and enrollment into the program. The enrollment kit is sent via mail.
Applicants
Signature: (Confirm)*		  
     

 


This plan is NOT insurance.

This discount card program contains a 30 day cancellation period.
FL, LA, MD, ND, OK, SC, SD and TX residents: Member shall receive a full refund of membership fees, excluding registration fee, if membership is cancelled within the first 30 days after the effective date. AR and TN residents: A refund of all fees will be issued if membership is cancelled within the first 30 days. Discount Medical Plan Organization: New Benefits, Ltd., Attn: Compliance Department, PO Box 671309 Dallas, TX 75367-1309

Form Number: 4150




 


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