USA Health Benefits

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Your Information
First Name:
Last Name:
Male:	Female:
Date of Birth:
Email:
Social Security:
Agent:
Address:
Address:
City:
State:
Zip:
Daytime Phone:
Evening Phone:

Dependant Information
Full Name	DOB (MM/DD/YYYY)
Spouse:
Child 1:
Child 2:
Child 3:
List the names and dates of birth of Additional Dependants in the box below. Adding dependants will not change your program price.
Additional Dependants

Select Package Type

Credit Card Information

Card Type:

Full Name:

Card Number:

Expiration Date:

Security Code:
(usually in the back)

Pay by Checking/Savings Account

Bank Name:

Account Type: Checking
Savings

Your Next Check #:
(checking only)

Enter the numbers from the bottom of your check:

Bank Routing Code:
Bank Account Number:

I/We have read, understand and agree to the terms and conditions below.
I/We certify that all the information is true and correct to the best of my/our knowledge

Disclosure

Your signature authorizes USA Health Benefits, Inc. and/or its assigns to debit your checking/savings account or charge your credit/debit card for the initial payment to start your program. Your initial charge includes your first month's payment plus a non-refundable application fee, and will be processed upon our receipt of this signed form. After your initial payment, your next draft or charge will occur on or after the 1st day of the month following your effective date. For example, if your program's effective date is August 1st; your next draft or charge will be on or after September 1st. If your program's effective date is September 1st, your next draft or charge will be on or after October 1st, and so on. Your signature gives USA Health Benefits, Inc. and/or its assigns authority to process your payment each month via an automated debit to your checking or savings account, or charge your credit/debit card, for the exact amount according to the program you selected. If funds in your account are not sufficient to cover the debit, USA Health Benefits assumes NO liability for any non-sufficient or other bank charges that may occur. Further, we reserve the right to attempt to process the payment a 2nd time, on or around the 10th day of the month. Because this is a medical savings program and not a comprehensive health insurance program, there is no waiting period once your program is effective. When used properly with a participating provider, your program entitles you to re-pricing on a wide variety of medical and dental procedures, and discounts on prescription drugs, optical care, chiropractic care, and other services. Savings can vary from provider to provider, and can be substantial. Use of doctor and hospital care may require pre-certification. Refer to your membership materials for specific procedures that must be followed to use your program correctly. Failure to not follow the correct procedures may result in the member not receiving the expected savings. The Accident and Disability policies, if part of your program, are actual insurance policies whereby the policy-holder may be eligible to file a claim for re-imbursement of losses based on events covered in the active policy. USA Health Benefits reserves the right to cancel your program for non-payment with no notice to the member. If you wish to cancel your program, we must receive notice to cancel on or before the 25th of the month, to avoid a charge for the next month. If you cancel after the 25th, your account will be debited for the next month, and your coverage will terminate at the end of that month. To receive a faxed confirmation of your cancellation, fax your request, with a return fax number, to 1-866-313-1194. Program covers only: primary member, spouse, and dependent children under age 19, or under age 25 if full-time student, or if disabled. I certify that the information on this form is correct and I have read and agree to the terms set forth in this document.

Disclosures:
1. THIS PLAN IS NOT INSURANCE. THIS IS NOT A MEDICARE PRESCRIPTION DRUG PLAN.*
2. 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.
3. The plan does not make payments directly to the providers of medical services.
4. 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.
5. Before purchase, you may access a list of participating health care providers at [searchforaprovider.com or clients website]. Upon request the plan will make available a written list of participating health care providers.
6. 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.
7. Discount Medical Plan Organization and administrator: Careington International Corporation, 7400 Gaylord Parkway, Frisco, TX 75034; phone 800-441-0380.
Note to Texas Consumers: Regulated by the Texas Department of Licensing and Regulation, P.O. Box 12157, Austin, Texas 78711; telephone 1-800-803-9202 or (512)463-6599 website: www.license.state.tx.us/complaints. The program and its administrators have no liability for providing or guaranteeing service by providers or the quality of service rendered by providers. *Medicare statement applies to MD residents when pharmacy discounts are part of program. This program is not available in Montana and Vermont