Discount Medical Plan Application
Step 1 - Enter PCI card holder's Information

2 Easy Steps:
1. Enter PCI card holder's Info
2. Enter Payment Info
  Procard Discount Benefits.
Dental, Prescription, Vision, Physician & Doctors by phone

Monthly Fee:

49.95/month*

*Please Enter your Sponsor's Access Code:
(If you do not have an access code, please tell us how you found out about us)


*Please Enter PCI card holder's Information:
*First Name:
M.I.:
*Last Name:
*Date of Birth:
   
*Gender:
*Street Address 1:
Street Address 2:
*City:
*State:
*Zip Code:
*Primary Phone:
Secondary Phone:
*E-mail Address (for confirmation e-mail):
Please Enter Dependent's Information
Your immediate family is included with this plan. Please enter the names of your legal dependents that you would like to have covered below:
Family with 2 children

Your membership is effective upon receipt of membership materials.

This is NOT insurance nor is it intended to replace insurance. This discount card program contains a 30 day cancellation period. The plan is not insurance coverage and does not meet the minimum creditable coverage requirements under the Affordable Care Act or Massachusetts M.G.L. c. 111M and 956 CMR 5.00. This plan provides discounts at certain healthcare providers for medical services. This plan does not make payments directly to the providers of medical services. The plan member is obligated to pay for all healthcare services but will receive a discount from those healthcare providers who have contracted with the discount plan organization. For a full list of disclosures, please click here. | Limitations, Exclusions and Exceptions | Discount Plan Organization: New Benefits, Ltd., Attn: Compliance Department, PO Box 803475, Dallas, TX 75380-3475.

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Form # 500-W