Thank you for deciding to join our plan. Your membership information will be sent via USPS First Class Mail and should arrive within 10 business days. Remember, your complete satisfaction is very important to us and all of our plans are backed by our iron-clad money back guarantee. Please refer to the membership materials for important Customer Service numbers and other important membership details.
Please complete this order form and click on the 'Submit' button to confirm your subscription. Your credit card will be charged the amount indicated on the form.
Your order will be reviewed for accuracy and we may contact you to confirm your choices and for security purposes.
Your membership booklet will contain important Customer Service contact information for any changes or cancellations.
Your plan contains the items listed below. You can click on any of the services to learn more about their specific features:
Hearing Aids
Alternative Health and Wellness
Chiropractic
Pharmacy Card 1
Physician and Hospital Network - Blend
Consult A Doctor ™ w/o Consult Fee
Your credit card will be charged the following:
monthly fee of $17.95 one-time registration fee of $4.95
Your first and last name:
Your email address (for your order confirmation):
Your phone number:
Please provide us with your billing address. Please make sure to provide accurate information in order to avoid processing delays.
Your street address:
Your city, state and Zip code:
Please provide us with the shipping address for this order. If your billing and shipping addresses are the same, please check the box below.
Same as Billing Information
First and last name:
Shipping street address:
Shipping city, state and Zip code:
Dependent information is not required for the purchase of discount benefit plans. All family members 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 add them to the list below. Each dependent card requested will result in a one-time printing charge of $2.50 in addition to the price of your benefit purchase today. All recurring payments will be processed for the price of benefits only (when applicable).
Your Credit Card Number:
We accept all major credit cards
Your Credit Card Expiration Date:
Your credit card CV Number (what is this?):
BQKEYLIFE-W
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Disclosures
This plan is NOT insurance
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
This discount card program contains a 30 day cancellation period.
FL, MD, ND, OK, SC, SD, LA and TX residents: Member shall receive a full refund of membership fees, excluding registration fee, if membership is cancelled within the first 30 days after the effective date.
AR and TN residents: A refund of all fees will be issued if membership is cancelled within the first 30 days.
MA Residents: The plan is not insurance coverage and does not meet the minimum creditable coverage requirements under M.G.L. c. 111M and 956 CMR 5.00.
Discount Medical Plan Organization: New Benefits, Ltd. Attn: Compliance Department, PO Box 671309 Dallas, TX 75367-1309.
Telephone number of Discount Medical Plan Organization: 800-800-7616
Internet website address to obtain participating providers, http://www.benefiq.com/providers.aspx
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. 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.