Online Registration




,

Email:
Dependents:

Dependents:

Dependent Information ():





You have selected . Would you like to upgrade your plan to AllCare Individual Family to have more benefits available to you? my family?



Yes, upgrade me now.

AllCare Individual Plan Family Plan
(Not available to WA, KS, UT, MD & VT residents)
(FREE for the first month and $24.99 per month thereafter) (FREE for the first month and $29.99 per month thereafter)
- See table below for details  
   No, keep my current plan

(Not available to WA, KS, UT, MD & VT residents)
FREE for the first month and $14.99 per month thereafter)"; }else if($_POST['plan']=="rxFam"){ echo "(FREE for the first month and $19.99 per month thereafter)"; }else if($_POST['plan']=="dtInd"){ echo "(FREE for the first month and $7.99 per month thereafter)"; }else if($_POST['plan']=="dtFam"){ echo "(FREE for the first month and $10.99 per month thereafter)"; } ?>
- See table below for details  








 
Rx

Dental

AllCare
Prescription Plan  
Galaxy Physician Hospital Discounts    
Dental Benefit  
Vision Plan    
Hearing Aids
Diabetic Supplies
Vitamins  
get_results($sql); $lastid_obj = $lastid_sql[0]; $rx_orderNum = $lastid_obj->ID; $colums = array( 'form_id' => $form_id, 'type' => $plan, 'plan' => $_POST['plan'], 'prefix' => $prefix, 'first' => $first, 'middle' => $middle, 'last' => $last, 'email' => $email, 'dob' => $dob, 'home_phone' => $home_phone, 'work_phone' => $work_phone, 'company' => $company, 'address1' => $address1, 'address2' => $address2, 'city' => $city, 'state' => $state, 'zip' => $zip, 'dependants' => $dependants ); ?>

Online Registration

Plan selected:
Charges
FREE
Monthly: $14.99
"; }else if($_POST['plan']=="rxFam"){ echo "First Month: FREE
Monthly: $19.99
"; }else if($_POST['plan']=="dtInd"){ echo "First Month: FREE
Monthly: $7.99
"; }else if($_POST['plan']=="dtFam"){ echo "First Month: FREE
Monthly: $10.99
"; }else if($_POST['plan']=="allInd"){ echo "First Month: FREE
Monthly: $24.99
"; }else if($_POST['plan']=="allFam"){ echo "First Month: FREE
Monthly: $29.99
"; } ?>

Check Detail:

Account holder name
Account number

Routing number
Account type

By checking this box, I acknowledge that I have read terms and conditions posted on the website. Health Benefit Plans, Inc. will begin charging my credit card /mo after the first free month. Discount Medical Plan Organization (DMPO): New Benefits, Ltd., Attn: Compliance Department, PO Box 671309, Dallas, TX 75367-1309.




Discount Plan Application      UPDATE YOUR PROFILE HERE

Compare Plans Prescription Dental AllCare
Prescription Plan  
Galaxy Physician Hospital Discounts    
Dental Benefit  
Vision Plan    
Hearing Aids
Diabetic Supplies
Vitamins  

JOIN FREE FOR A MONTH

Limited Time Offer. Cancel Anytime.
  • Plans
  • RX Plan Individual

    (Not available to WA, KS & UT
    residents)

    FREE for the first month and $14.99/month thereafter

  • RX Plan Family

    (Not available to WA, KS & UT
    residents)

    FREE for the first month and $19.99/month thereafter

  • Dental Plan Individual

    (Not available to WA, KS, UT
    & VT residents)

    FREE for the first month and $7.99/month thereafter

  • Dental Plan Family

    (Not available to WA, KS, UT
    & VT residents)

    FREE for the first month and $10.99/month thereafter

  • AllCare Plan Individual

    (Not available to WA, KS, UT, MD
    & VT residents)

    FREE for the first month and $24.99/month thereafter

  • AllCare Plan Family

    (Not available to WA, KS, UT, MD
    & VT residents)

    FREE for the first month and $29.99/month thereafter

  • - See table above for details


By submitting this form, I acknowledge receipt and acceptance of the disclosures listed below.