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Online Application

DISCOUNT MEDICAL PLAN ENROLLMENT APPLICATION

6923 NW 77 Ave. Miami, Fl. 33166
Phone:(305) 400-4843 / Fax: (305) 517 - 3470

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

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Name and Last Name MEMBER 3

DOB

Sex
 M F

Relationship with Principal Applicant

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Name and Last Name MEMBER 4

DOB

Sex
 M F

Relationship with Principal Applicant

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Name and Last Name MEMBER 5

DOB

Sex
 M F

Relationship with Principal Applicant

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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 is a Discount Medical Plan, licensed and authorized by the State of Florida. The term of this agreement is on a month to month basis. This Enrollment Application and the Members’ Handbook represent the entire agreement between you and AMIGOS and supersede all other prior representations, statements, or written agreements between you and AMIGOS.
TERM, CONDITIONS & DISCLOSURES
1. The effective date of Member’s membership commences on the date the Member signs this Application. Members may cancel their Membership at any time without restriction or penalty. If a Member cancels this plan within the first 30 days of the effective date, the member will receive a 100% refund (minus the one time processing fee). This is done by submitting a written notification to AMIGOS.
2. AMIGOS membership Cards are usually received within ten (10) business days of signing this Enrollment Application. However, you are eligible to receive all of the benefits we offer immediately after the effective date, using this application or by calling AMIGOS for assistance.
3. Failure to keep membership fees up to date will result in a temporary suspension of membership until the matter is resolved. A Member may cancel his/her membership at anytime. Cancellations must be in writing. The enrollment Term will be renewed automatically if no such cancellation request is made. At any time, Members may add up to five (5) members to their membership or cancel their Membership. To add additional members, you must inform AMIGOS in writing.
4. A cancellation notice must include the return of the Member’s Amigos Medical Plan Card(s).
5. This plan is NOT insurance and does not meet the minimum creditable coverage requirements under M.G.L. c. 111M and 956 CMR 5.00
6. This plan provides discounts at certain healthcare providers for medical services.
7. This plan does not make payments directly to the providers of medical services.
8. The member is obligated to pay for all healthcare services at the time of service, but will receive a discount from those healthcare providers provided they are in our network.
9. Amigos Medical Plan is a Discount Medical Plan Organization licensed per chapter 636, located at 6923 NW 77thAvenue, Miami, FL 33166 / (800) 764 - 79634 / www.amigosmedicalplan.com.
10. The range of discounts for medical or ancillary services provided under the plan will vary depending on the type of provider and medical or ancillary service received.

11. The discount medical card program makes available, before purchase and upon request, a list of program providers, including the name, city, state, and specialty of each program provider located in the cardholder’s service area.
12. A $25 charge will be applied to all returned checks or if a bank debit or authorized credit transaction is not completed due to problems, including items such as insufficient funds, closed accounts, stop payment orders, or incorrect account numbers.
13. The members hereby agree to obtain the DMPO plans documents forms through the AMIGOS website at: www.amigosmedicalplan.com or by calling AMIGOS Customer Services Department and requesting a hard copy be mailed via U.S regular mail.
A DESCRIPTION OF CUSTOMER SERVICES AND MEMBER COMPLAINT PROCEDURES
14. Our Customer Service operators can be reached Monday to Friday, 9:00 am to 5:00 pm. The phone number is (305) 400-4843 or (800) 764-7964. Members may call AMIGOS Customer Services Department or make a complaint in writing to Amigos Medical Plan at 6923 NW 77 Ave, Miami, FL 33166.
15. Complaints about network providers will be forwarded to the provider in question and complaints about Amigos Medical Plan services will be handled by the AMIGOS Customer Services Department. AMIGOS will respond to Member’s complaint within three (3) business days of receiving such complaint. Upon resolution of the complaint Amigos Medical Plan will send Member a written resolution report.
CONTACT US
16. You may contact medical providers directly to make appointments or our customer service representatives will make doctor appointments on your behalf at your request. You may contact us at:
a) Phone: (305) 400-4843or (800) 764-7964.
b) Email, Fax, Website -:
i) email: amigoshelp@gmail.com.com
ii) fax: (305) 517 - 3470 or
iii) website: www.amigosmedicalplan.com

Download Application

DMPO Individual Application


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