Step 1. Plan Selection
Step 2. Shipping Information
Step 3. Payment Options
Step 4. Confirmation Page
 
Discount Medical Plan Application

Shipping Information
* - Required Fields
First Name  *
Last Name *
   
Shipping Address 1 *
Shipping Address 2
City *
State *
Zip *
   
Contact Phone Number *
Gender *
Date of Birth / / *
E-mail *
Language *
   

Dependent information is not required for the purchase of discount benefit plans.  All legal dependents can receive discounts using the card issued in the main member’s name.  If you would like to receive additional cards reflecting the name of your dependents, please first select the appropriate number of dependents and then list their information below. Each dependent card requested will result in a one-time printing charge in addition to the price of your benefit purchase today.  All recurring payments will be processed for the price of benefits only (when applicable).

Number of Dependents Qualifications

 

 


 
Order Summary
HEALTH PERX
Monthly
$15.99/mo.
Total: $15.99 1st month
$15.99 Each month thereafter
Merchant Services

Your membership is effective upon receipt of membership materials.


This is not insurance nor is it intended to replace insurance. This discount card program contains a 30 day cancellation period. This plan provides discounts at certain healthcare providers for medical services. This plan does not make payments directly to the providers of medical services. The plan member is obligated to pay for all healthcare services but will receive a discount from those healthcare providers who have contracted with the discount plan organization. For a full list of disclosures please Click Here. Discount Medical Plan Organization: New Benefits, Ltd., Attn: Compliance Department, PO Box 671309, Dallas, TX 75367-1309


Form # NB-35242L Privacy Policy