AmeriPlan Health® Membership Application
Medical-Dental-Vision-Prescription-Chiropractic
Broker#
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First Name
MI
Last Name
                                 
 
                                 
Date of Birth of Applicant Male/Female Residence or Work Telephone        Alternate Telephone
   

   

   
 
 
     

     

       
     

     

       
Mailing Address        Apt.#
                                                                 
       
City State Zip
                             
   
           
 

LIST OF HOUSEHOLD MEMBERS
E-MAIL-ADDRESS  
First Name Last Name Date of Birth LIST
ADDITIONAL
HOUSEHOLD
MEMBERS ON
REVERSE SIDE
                       
                       
   
 
   
 
   
                       
                       
   
 
   
 
   
                       
                       
   
 
   
 
   
                       
                       
   
 
   
 
   
                       
                       
   
 
   
 
   

By signing the drafting authorization below, I hereby acknowledge that I have read and understand that AmeriPlan Health® is NOT insurance. AmeriPlan Health® is a discount fee-for-service plan and I must pay any charges at the time services are rendered.
 
I understand my membership is on an annual basis and all membership fees are non-refundable after 30 days.

I WANT TO PAY MY MONTHLY OR QUARTERLY MEMBERSHIP FEE BY:
 BANK DRAFT:  Please Draft on the
 
3rd or
 
18 of the month.
By Submitting Your enclosed check,you are authorizing the ongoing draft until AmeriPlan® is notified of cancellation in writing.
X

SIGNATURE FOR BANK DRAFT
CREDIT CARD:
    
 Visa
    
 Master Card
    
 Discover
    
 American Express
Card# Expiration Date
                               
   
 
   
   
X

SIGNATURE FOR CREDIT CARD
A One time $30.00 Registration Fee is required with each application.
 First Month Membership Fee
 (Monthly Fee: $49.95 Single/$59.95 Family)
$

 First Quarter Membership Fee
 (Quarterly Fee: $149.85- Single/$179.85  Family)
$

 First Year Membership Fee
 (Annual Fee:$599.40 Single/$719.40  Family)
$

 One-time Registration Fee
         Non Refundable
$ 30.00

 TOTAL AMOUNT DUE  
$

30-day written cancellation notice

MONTHLY OR QUARTERLY PAYMENTS MUST BE MADE BY ELECTRONIC BANK DRAFT OR BY CREDIT CARD.
INVOICING IS AVAILABLE FOR ANNUAL MEMBERSHIPS ONLY WITH FIRST YEAR PAID IN ADVANCE
Enclose your check for payment and a voided check if paying monthly or quarterly by bank draft -30 day written cancellation notice required.
 
Complete and mail application to:

Ameriplan USA®, 5700 Democracy Drive, Plano, TX 75025
or you can fax to 469-229-4589