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Your Membership ID #
First Name
Last Name
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Zip Code
Credit Card #
Expiration Date
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Complete only for Bank Draft only* ( on the 15th of each month):


Bank “routing” number *
Bank “account” number *

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DISCLOSURE: This plan is NOT insurance. The plan provides discounts at certain health care providers for medical services. The plan does not make payments directly to the providers of medical services. The plan member is obligated to pay for all health care services but will receive a discount from those health care providers who have contracted with the discount plan organization.
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