Register/Registrese        Login/Acceder

prueba para formulario

  • -

prueba para formulario

Category : Uncategorized

PERSONAL INFORMATION

Primary Applicant Name (required)

Last Name (required)

DOB (required)

Sex (required)
 M F

Address / Apartment (required)

City / State / Zip Code (required)

Phone (required)

Email (required)

ADDITIONAL MEMBERS INFORMATION

Name and Last Name MEMBER 2

DOB

Sex
 M F

Relationship with Principal Applicant

------------------------------------------------------

Name and Last Name MEMBER 3

DOB

Sex
 M F

Relationship with Principal Applicant

----------------------------------------------------------------------------

Name and Last Name MEMBER 4

DOB

Sex
 M F

Relationship with Principal Applicant

-----------------------------------------------------------------------

Name and Last Name MEMBER 5

DOB

Sex
 M F

Relationship with Principal Applicant

-----------------------------------------------------------------------

Name and Last Name MEMBER 6

DOB

Sex
 M F

Relationship with Principal Applicant

PAYMENT INFORMATION WITHDRAWAL AUTHORIZATION FORM

credit logo png

Card Type
 Visa Mastercard Amex Discovery

Payment Information
 First & Recurring Payment Only First Payment Recurring Payment

Card Holder Complete Name

Card Number

Expiration Date

Security CVV

Billing Address if different

Check-Image (1)

Payment Information
 First & Recurring Payment Only First Payment Recurring Payment

Routing Number

Account Number

Bank Name

Account Holder Complete Name

money-order

Money Order Information #

SELECTED PLAN MONTHLY PRICES

Basic Discount Medical Plan (required)
 Individual and/or Family Plan $30 One time Registration Fee $30 Total Amount First Payment $60

Printed Name Principal Applicant and Signature

Date

Amigos Medical Plan (AMIGOS) is a Discount Medical Plan, licensed by the State of Florida. AMIGOS should not replace any health insurance or indemnity insurance. DISCLAIMER: The Amigos Medical Plan, “Basic Discount Medical Plan” is NOT an insurance plan. AMIGOS plans provide discounts at certain health care providers for medical services. Amigos does not make payments directly to the providers for medical services. Members must pay for all healthcare services at the time services are rendered and at the established discounted rate negotiated between AMIGOS and the Network Providers. Any person who knowingly files a statement of claim or an application for membership with AMIGOS, with intent to injure, defraud or deceive AMIGOS may be guilty of a felony of the third degree. I certify that I have read the statements on this form, or that they have been read to me, and that all the information I provided is true and complete to the best of my knowledge. A facsimile of this signed authorization may be considered an original. I understand that this agreement will remain in full effect until I provide AMIGOS with written notice of cancellation.


s2Member®