AmeriPlan® USA Enrollment Application
Dental-Vision-Prescription-Chiropractic Plan
Enrolling Broker Number
1
2
6
0
4
9
7
9
First Name
MI
 Last Name
                                 
 
                                 
Date of Birth of Applicant Male/Female Social Security #        Residence or Work Telephone
   
   
   
 
 
     
   
       
     
     
       
Mailing Address        Apt.#
                                                                 
       
City State Zip  Applicant's Employer
                             
   
           
                           
LIST OF HOUSEHOLD MEMBERS
E-MAIL-ADDRESS  
First Name Last Name Date of Birth
LIST OTHER HOUSEHOLD
MEMBERS ON REVERSE SIDE
 I WANT MY MEMBERSHIP
 MATERIALS IN :
 ENGLISH
 SPANISH
                       
                       
   
  
   
  
   
                       
                       
   
  
   
  
   
                       
                       
   
  
   
  
   
                       
                       
   
  
   
  
   
                       
                       
   
  
   
  
   
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:  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 $20.00 Registration Fee is required with each application.
 First Month Membership Fee
 (Monthly Fee: $11.95 Single/$19.95 Family)
 
 First Quarter Membership Fee
 (Quarterly Fee: $35.65- Single/$59.85  Family)
 
 First Year Membership Fee
 (Annual Fee:$143.40 Single/$239.40  Family)
 
 One-time Registration Fee
20.00
 TOTAL AMOUNT DUE  
 
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 payment and a voided check if paying monthly or quarterly by bank draft -30 day written cancellation notice required.
 
Please mail to:
AmeriPlan®, Attn:  Application Processing, 5700 Democracy Drive, Plano, TX 75024
 
AmeriPlan® BENEFITS ARE NOT INSURANCE
This is a Discount Medical Plan Organization NOT a Health Insurance Policy. 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 all heath care services but will receive a discount from those heath care providers who have contracted with the Discount Medical Plan Organization. AmeriPlan® Corporation 5700 Democracy Drive Plano, TX 75024.
Click here for additional disclosures.