Plan Selection ( 1 - 6 )
- (1) (2) (3) (4) (5) (6)
0 - 50k Indemnity? (Yes or No)
- (Yes) (No)
Over 50k Stop Loss? (Yes or No)
- (Yes) (No)
First Name:
Middle Initial:
Last Name:
Sex:
Date of Birth
Identification type (SS, DL, or PassPort)
Home Address
City
State
ZIP
Mailing Address
City
State
ZIP
Primary Phone
Other Phone
Email Address
Add-on Spouse or Dependent?
- (Yes) (No)
Plan Selection ( 1 - 6 )
- (1) (2) (3) (4) (5) (6)
0 - 50k Indemnity? (Yes or No)
- (Yes) (No)
Over 50k Stop Loss? (Yes or No)
- (Yes) (No)
First Name
Middle Initial
Last Name
Sex:
Date of Birth
Identification type (SS, DL, or PassPort)
Add-on Spouse or Dependent?
- (Yes) (No)
Plan Selection ( 1 - 6 )
- (1) (2) (3) (4) (5) (6)
0 - 50k Indemnity? (Yes or No)
- (Yes) (No)
Over 50k Stop Loss? (Yes or No)
- (Yes) (No)
First Name
Middle Initial
Last Name
Sex:
Date of Birth
Identification type (SS, DL, or PassPort)
Add-on Spouse or Dependent?
- (Yes) (No)
Plan Selection ( 1 - 6 )
- (1) (2) (3) (4) (5) (6)
0 - 50k Indemnity? (Yes or No)
- (Yes) (No)
Over 50k Stop Loss? (Yes or No)
- (Yes) (No)
First Name
Middle Initial
Last Name
Sex:
Date of Birth
Identification type (SS, DL, or PassPort)
The basic cooperative membership includes lab services from CPL and Telemedicine from Teladoc, 24/7/365 and eligibility for all the other plans offered. It is paid annually by Debit, CC or Bank Draft. I (we) agree to abide by the terms of the PPC membership as printed in the Membership Booklet. If paid by payroll deduction I (we) authorize the employer above to honor and pay these charges which may include the monthly payment plans as well as the annual membership fee. I (we) understand that in order to cancel these payments, I (we) must provide written notice to Patient/Physician Cooperatives and Group Employee Benefit Plan no less than 30 days before the next scheduled payment. Until such notice is received, I (we) agree that you shall be fully protected in honoring any such charge/draft.
Primary Care Services Agreement I agree to a one-year contract with my selected Provider for access to primary care services. I understand any requests to change providers prior to the end of my 12-month contract must be submitted in writing to be reviewed and approved by Member Services.
Imaging Services Agreement I agree to a one-year contract with my selected Provider for access to imaging services. I understand any requests to change providers prior to the end of my 12-month contract must be submitted in writing to be reviewed and approved by Member Services.
Lab Services Agreement I agree to a one-year contract with my selected Provider for access to primary care services. I understand any requests to change providers prior to the end of my 12-month contract must be submitted in writing to be reviewed and approved by Member Services.
Specialty Group Care Services Agreement I agree to a one-year contract with my selected Specialty Group Provider for access to primary care services. I understand any requests to change providers prior to the end of my 12-month contract must be submitted in writing to be reviewed and approved by Member Services.
Terms and Agreement for Bank Authorization I (we) authorize the financial institution named below to honor and pay these membership charges. This authority is to remain in effect until revoked by me (us) in writing, and until you actually receive such notice. I (we) agree that you shall be fully protected in honoring any such check/draft or credit/debit card charge. I (we) understand that in order to cancel this automatic deduction, I (we) must provide written notice to the Senior Patient Association no less than 15 days before the next scheduled automatic deduction.
Method of Payment: (Bank Draft, Debit, Credit)
Bank Draft: Bank Name:
Routing:
Account:
Credit, Debit, Visa, MC, Amex, Discover?
Name on the Card
Card #:
Exp. Date
CSV Code
I certify that I have given an outline of coverage for the policy applied for by this applicant.
Name of your agent? Disregard if you don not have an agent who referred you.
Send
