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8300 West Flagler St Suite 175 Miami , Fl. 33144
Tel. (305) 220-4915 Fax (305) 220-1472

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DISCLAIMER : The Amigos Medical Plan , “Basic Discount Medical Plan” is NOT an insurance .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 services at the time services are rendered and at the established discounted rate negotited between Amigos and the Network Providers.Any person who knowingly files a statement of clain or an aplication 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 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 concidered an original. I understand that this agreement will remain in full effect until I provide Amigos with written notice of cancelation.

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