APPLICATION

Access Healthplex Discount Dental and Vision Plan

MEMBER INFORMATION

TELL US ABOUT YOURSELF

PAYMENT INFORMATION

CREDIT CARD,
DEBIT CARD
OR CHECK

CONFIRM

REVIEW AND AGREE

FIRST NAME*

LAST NAME*

STREET ADDRESS*

CITY*

STATE*

ZIP*

DATE OF BIRTH* (MM/DD/YYYY)

MARITAL STATUS*

HOME PHONE* (NO SPACES OR DASHES)

EMAIL ADDRESS*

REFERRED BY

DEPENDENT INFORMATION

Note: Coverage is available for spouse, domestic partner or dependent children up to age 26.

Please contact our sales department at 1-800-468-0466 if more than 5 dependents are to be enrolled.

	FIRST NAME	MI	LAST NAME	RELATIONSHIP	DATE OF BIRTH
1

2

3

4

5

DISCLOSURES Read More

THIS PLAN IS NOT INSURANCE.

This plan does not meet the minimum creditable coverage requirements under M.G.L. c. 111M and 956 CMR 5.00. This plan is not a Qualified Health Plan under the Affordable Care Act. THIS IS NOT A MEDICARE PRESCRIPTION DRUG PLAN.^* The plan provides discounts at certain health care providers for medical services. The range of discounts will vary depending on the type of provider and service. The plan does not make payments directly to the providers of medical services. Plan members are obligated to pay for all health care services but will receive a discount from those health care providers who have contracted with the discount medical plan organization. You may access a list of participating health care providers at www.healthplex.com. Upon request the plan will make available a written list of participating health care providers. You have the right to cancel within the first 30 days after receipt of membership materials and receive a full refund, less a nominal processing fee (nominal fee for MD residents is $5). Discount Medical Plan Organization and administrator: Careington International Corporation, 7400 Gaylord Parkway, Frisco, TX 75034; phone 800-441-0380.

The plan and its administrators have no liability for providing or guaranteeing service by providers or the quality of service rendered by providers. This plan is not available in Montana and Vermont. This plan is not currently available in Washington. * Medicare statement applies to MD residents when pharmacy discounts are part of plan.

Payment Method
Please select a payment method

Payment Due: 0.00
Includes $15 processing fee

CREDIT CARD

Visa

MasterCard

Discover

NAME ON CARD

CARD NUMBER

EXP. DATE

CHECK

Check Payable to: Healthplex, Inc.

Mail To:
Billing Department
Healthplex, Inc.
333 Earle Ovington Boulevard, Suite 300
Uniondale, NY 11553

You will be signed up once the payment is received.

Members will remain active unless member notifies Healthplex, Inc. of their request to cancel prior to the renewal date. Understand that your credit card will be automatically charged for the appropriate annual renewal amount.

Form code: AH-2012