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Step 1

Discount Medical Plan Application

Your Account Information
Please provide all of the following information.
Gender: Male Female

Phone (1112223333):
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Form: exrx-03659-1

Your membership is effective upon receipt of membership materials.

This is NOT insurance nor is it intended to replace insurance. This discount card program contains a 30 day cancellation period. The plan is not insurance coverage and does not meet the minimum creditable coverage requirements under the Affordable Care Act or Massachusetts M.G.L. c. 111M and 956 CMR 5.00. 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. For a full list of disclosures, please click here. | Limitations, Exclusions and Exceptions | Discount Plan Organization: New Benefits, Ltd., Attn: Compliance Department, PO Box 803475, Dallas, TX 75380-3475.